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BUKIDNON STATE UNIVERSITY College of Nursing Malaybalay City, Bukidnon

In Partial Fulfilment of the Course Requirement in NCM 106

A Case Presentation on Breast Cancer Stage IIIB

Presented by: Abecia, Lech Mahonri V. Bandao, Hananeel M. Conde, Florie May C. De los Reyes, Rovelyn B. Dumasis, Efryl Igot, Paula Luz Magsayo, Quennie May L. Molina, Erbert Sweet Anne S. Neri, Ivyn Ian G. Olarte, Glaiza Lorraine K. Quizon, Alma Sheila S. Sala, Florsean Mae A. Talose, Novalhiza C.

Presented to: 4th Year Nursing Students and Clinical Instructors of BSU CON

TABLE OF CONTENTS

I. II. III. IV. V. VI. VII.

GENERAL OBJECTIVES SPECIFIC OBJECTIVES INTRODUCTION ASSESSMENT ANATOMY AND PHYSIOLOGY PATHOPHYSIOLOGY TREATMENT UTILIZED ACTUAL LABORATORY DIAGNOSTIC EXAM DRUG STUDY IDEAL TREATMENT NURSING CARE PLANS ACTUAL NURSING CARE PLANS IDEAL NURSING CARE PLANS HEALTH TEACHINGS DOCTORS ORDER PROGNOSIS RESEARCH UPDATE

2-7 8 - 15 16 - 18 19 - 21

22 - 27 28 - 55 56 - 65 66 - 76 77 - 83 84 - 88 89 - 97 98 - 99 100 - 102

VIII. IX.

X. XI. XII. XIII.

I.

GENERAL OBJECTIVES This case presentation seeks to enhance the students knowledge with regards to Breast Cancer Stage IIIB. This also seeks to enhance students learning, skills and attitude through application of several nursing interventions and medical management.

II.

SPECIFIC OBJECTIVES At the end of 4 hours, the student nurses will be able to:

1. Discuss about Breast Cancer Stage IIIB. 2. Present patients profile including data base and history. 3. Discuss an overview of Anatomy and Physiology of the Mammary Glands and Lymphatic System. 4. Explain the disease process of the patients condition. 5. Understand risk factors, signs and symptoms, and its underlying complications. 6. Identify and discuss the actual and ideal treatment and management on the patients condition. 7. Identify and discuss the ideal and actual nursing care plan for the patient. 8. Identify the nursing responsibilities for the patient with Breast Cancer Stage IIIB. 9. Discuss the health teachings intended for the client.

III.

INTRODUCTION

In many cultures, the breast plays a significant role in a womans sexuality and identification of herself as female. Although advances in the diagnosis and treatment of breast disorders are changing the prognosis for breast disease and cancer, womens responses to possible breast disease include fear of disfigurement and loss of sexual attractiveness and fear of death. The woman with breast disease may undergo diagnostic testing, surgery, radiation therapy, chemotherapy, and hormonal therapy. Thus, nurses caring for patients with breast disease must have an in-depth understanding of these treatment modalities and expert assessment and clinical skills to address the physical and psychological needs of patients facing breast disorders, and their families. In Asia, the Philippines have the highest incident rate of breast cancer and is considered to have the ninth highest incident rate in the world today. Breast cancer is the leading cause of cancer and cancer deaths in Filipino women. Recently, more women are presenting with bilateral disease at an early age (30s-40s). Generally, the disease is still being diagnosed late in its course hence the survival rate of breast cancer in the Philippines is below 50%. Making the situation more difficult, an estimated seventy percent (70%) of breast cancer patients in the Philippines are indigents. If it is found in early stages (in situ with no node involvement), the 10-year survival rate is 70% to 75% compared with 20% to 25% when the nodes are positive. Breast cancer can recur even 20 to 30 years after the first diagnosis. Carcinoma of the breast stems from the epithelial tissues of the ducts and lobules. Breast cancer is classified as either noninvasive or invasive. Noninvasive carcinoma refers to cancer in the ducts or lobules and is also called carcinoma in situ (5% of breast cancers). Invasive carcinoma (also known as infiltrating carcinoma) occurs when the cancer cells invade the tissue beyond the ducts or lobules. The rate of cell division of the cancerous growth varies, but it is estimated that the time it takes for a tumor to be palpable will range from 5 to 9 years. When the cancer cells become invasive, they grow in an irregular or sunburst pattern that is palpated as a poorly defined lump or thickening. As the tumor continues to grow, fibrosis forms around the cancer, causing the Coopers ligaments to shorten, which results in dimpling of the skin. Advanced tumors will interrupt the lymph drainage, resulting in skin edema and an orange peel (peau dorange) appearance. Untreated cancer may erupt on the skin as ulceration. There is no single, specific cause of breast cancer; rather, a combination of hormonal, genetic, and possibly environmental events may contribute to its development. Gender is the most obvious risk factor for breast cancer in women. Increasing age is also associated with an increasing risk of breast cancer. Approximately 80% of breast cancers are diagnosed after 50 years of age (Jema et al., 2006). Once a woman has been treated for breast cancer, her risk of developing cancer in the same or opposite breast is significantly increased. Hormones produced by the

ovaries have an important role in breast cancer. Two key ovarian hormones, estradiol and progesterone, are altered in the cellular environment by a variety of factors, and these may affect growth factors for breast cancer. The role of hormones and their relationship to breast cancer remain controversial. Research suggests that a relationship exists between estrogen exposure and the development of breast cancer. In laboratory studies, tumors grow much faster when exposed to estrogen, and epidemiologic research suggests that women who have longer exposure to estrogen have a higher risk for breast cancer. Early menarche, nulliparity, childbirth after 30 years of age, and late menopause are known but minor risk factors. The assumption is that these factors are all associated with prolonged exposure to estrogen because of menstruation. The theory is that each cycle (which has high levels of endogenous estrogen) provides the cells of the breast another chance to mutate, increasing the chance for cancer to develop. Estrogen itself does not cause breast cancer, but it is associated with its development. Growing evidence indicates that genetic alterations are associated with the development of breast cancer. These genetic alterations include changes or mutations in normal genes and the influence of proteins that either promote or suppress the development of breast cancer. Genetic alterations may be somatic (acquired) or germline (inherited). To date, two gene mutations have been identified that may play a role in the development of breast cancer. A mutation in the BRCA-1 gene has been linked to the development of breast and ovarian cancer, whereas a mutation in the BRCA-2 gene identifies risk for breast cancer, but less so for ovarian cancer (Houshmand, Campbell, Briggs et al., 2000). It has been estimated that 1 of 600 women in the general population has either a BRCA-1 or BRCA-2 gene mutation. For women who carry either mutation, the risk for developing breast cancer can range from 50% to 90% (Kauff, Satagopan, Robson et al., 2002). Women who receive radiation during adolescence and early childhood are at an increased risk of breast cancer, which suggests that exposure to radiation causes potential aberrations while the breast tissues is still developing. Women at particularly high risk are those who received mantle radiation (to the chest area) for treatment of Hodgkin disease in their younger years. There was a Swedish study which examined 11, 726 postmenopausal women and did find a significantly increased risk for breast cancer with increased fat intake. (Mattisson, Wirfalt, Wallstrom et al., 2004). Research has also shown that use of alcohol increases the risk of breast cancer slightly. Women who consume one drink a day have a small increase in risk. With increasing alcohol intake (2 to 5 drinks a day), the risk may double. Women who consumed more than approximately 1.5 glasses of wine a day are twice as likely to develop breast cancer compared with women who drink little or no alcohol. Breast cancers occur anywhere in the breast, but most are found in the upper outer quadrant, where most breast tissue is located. Generally, the lesions are nontender rather than painful, fixed rather than mobile, and hard with irregular borders

rather than encapsulated and smooth. Techniques to determine the histology and tissue diagnosis of breast cancer include FNA, excisional (or open) biopsy, incisional biopsy, needle localization, core biopsy, and stereotactic biopsy. Types of Breast Cancer 1. Ductal carcinoma in situ (DCIS): This is a type of non-invasive breast cancer. DCIS means that the cancer cells are only in the ducts. They have not grown through the walls of the ducts into the tissue of the breast and so cannot spread to lymph nodes or other organs. Nearly all women with cancer at this stage can be cured. Mammograms find many cases of DCIS. 2. Invasive (or infiltrating) ductal carcinoma (IDC): This is the most common breast cancer. It starts in a milk passage (a duct), breaks through the wall of the duct, and invades the tissue of the breast. From there it may be able to spread (metastasize) to other parts of the body. It accounts for about 8 out of 10 invasive breast cancers. 3. Invasive (infiltrating) lobular carcinoma (ILC): This cancer starts in the milk glands (the lobules) and then spreads through the wall of the lobules. It can then spread (metastasize) to other parts of the body. About 1 in 10 invasive breast cancers are of this type. 4. Medullary Carcinoma: It accounts for about 5% of breast cancers, and it tends to be diagnosed more often in women younger than 50 years. The tumors grow in a capsule inside a duct. They can become large and may be mistaken for a fibroadenoma. The prognosis is often favourable. 5. Mucinous Carcinoma: This type of cancer accounts for about 3% of breast cancers and often presents in postmenopausal women 75 years and older. A mucin producer, the tumor is also slow-growing and thus the prognosis is more favourable than in many other types. 6. Tubular Ductal Carcinoma: This type of cancer accounts for about 2% of breast cancers. Because axillary metastases are uncommon with this histology, prognosis is usually excellent. 7. Inflammatory breast cancer (IBC): This uncommon type of invasive breast cancer accounts for about 1% to 3% of all breast cancers. Usually there is no single lump or tumor. Instead, IBC makes the skin of the breast look red and feel warm. It also may make the skin look thick and pitted something like an orange peel. The breast may get bigger, hard, tender, or itchy. 8. Paget Disease: Paget Disease of the breast accounts for 1% of diagnosed breast cancer cases. Symptoms typically include a scaly, erythematous, pruritic

lesion of the nipple. Paget disease often represents ductal carcinoma in situ of the nipple but may have an invasive component.

Staging involves classifying the cancer by the extent of disease. Clinical staging involves the physicians estimate of the size of the breast tumor and the extent of axillary node involvement by physical examination (palpable nodes may indicate progression of the disease) and mammography. After the diagnostic workup and the definitive surgical treatment, the breast cancer is staged according to the TNM system (Greene, Page, Fleming, et al., 2002), which evaluates the size of the tumor, number of nodes involved, and evidence of distant metastasis. The overall 5-year survival rate is 100% in Stage 0 when the cancer cells remain inside the breast duct, without invasion into normal adjacent breast tissue. In stage I, the cancer cell is 2 centimeters or less and is confined to the breast (lymph nodes are clear) with a 5-year survival rate of 98%. Stage IIA with a survival rate of 88% presents no tumor to be found in the breast, but cancer cells are found in the axillary lymph nodes (the lymph nodes under the arm); or the tumor measures 2 centimeters or smaller and has spread to the axillary lymph nodes; or the tumor is larger than 2 but no larger than 5 centimeters and has not spread to the axillary lymph nodes. In Stage IIB when the tumor is larger than 2 but no larger than 5 centimeters and has spread to the

axillary lymph nodes or when it is larger than 5 centimeters but has not spread to the axillary lymph nodes, the 5-year survival rate decreases to 76%. The rate further decreases into 56% in Stage IIIA when there is no tumor found in the breast. In this stage, cancer is found in axillary lymph nodes that are sticking together or to other structures, or cancer may be found in lymph nodes near the breastbone. In Stage IIIB, however, the tumor may be any size and has spread to the chest wall and/or skin of the breast and it may have spread to axillary lymph nodes that are clumped together or sticking to other structures or cancer may have spread to lymph nodes near the breastbone. Inflammatory breast cancer is considered at least stage IIIB. Stage 3C breast cancer is broken into two distinct categories: operable and inoperable. A diagnosis of Stage IIIC breast cancer means the cancer has spread to lymph nodes found beneath the collarbone and in the area of the neck. This is categorized as operable. It may also have spread to the lymph nodes located within the breast itself, as well as underneath the arm and in tissues that are near the breast region. This may be categorized as inoperable. Overall, a diagnosis of Stage IIIC breast cancer has a fiveyear prognosis of only a 35% survival rate. Stage IV breast cancer has a survival rate of 16% in which the cancer has spread or metastasized to other parts of the body. The most common route of regional spread is to the axillary lymph nodes. DEFINITION OF TERMS Adenocarcinoma: An adenocarcinoma is a type of cancer that starts in gland tissue (tissue that makes and secretes a substance). The ducts and lobules of the breast are gland tissues because they make breast milk, so cancers starting in these areas are often called adenocarcinomas. Atypical hyperplasia: abnormal increase in the number of cells in a specific area within the ductal or lobular areas of the breast; this abnormal proliferation increases the risk for cancer. Benign proliferative breast disease: various types of atypical, yet noncancerous, breast tissue that increase the risk for breast cancer. BRCA-1: gene on chromosome 17 that, when damaged or mutated, places a woman at greater risk for breast or ovarian cancer, or both, compared with women who do not have the mutation. BRCA-2: gene on chromosome 17 that, when damaged or mutated, places a woman at greater risk for breast cancer (though less so than BRCA-1) compared with women who do not have the mutation. Breast-conservation therapy: surgery to remove a breast tumor and a margin of tissue around the tumor without removing any other part of the breast; may include an axillary lymph node dissection, radiation therapy, or both. Breast self-examination (BSE): technique for checking ones own breasts for lumps or suspicious changes. Carcinoma: This is a term used to describe a cancer that begins in the lining layer of organs such as the breast. Nearly all breast cancers are carcinomas (either ductal carcinomas or lobular carcinomas).

Estrogen and progesterone receptor assay: test to determine whether the breast tumor is nourished by hormones; this information is useful in making a prognosis and determining treatment. Fine-Needle Aspiration (FNA): the removal of fluid for diagnostic analysis from a cyst or cells from a mass using a needle and syringe. Galactography: use of mammography after an injection of radiopaque dye to diagnose problems in the ductal system of the breast. Lymphatic mapping and sentinel node biopsy: procedure using radiopaque dye and nuclear medicine techniques to iden-tify and analyze the first draining lymph node from the breast within the axillary region. Mammography: an x-ray of the breast; the principal method of screening for and detection of breast cancer in women. Mastalgia: breast pain, usually related to hormonal fluctuations or irritation of a nerve. Mastitis: inflammation or infection of the breast. Medullary carcinoma: special type of infiltrating breast cancer in which the tumor is well defined, with obvious boundaries. Modified radical mastectomy: removal of the breast tissue, nippleareola complex, and a portion of the axillary lymph nodes. Sarcoma: Sarcomas are cancers that start from connective tissues such as muscle tissue, fat tissue or blood vessels. Sarcomas of the breast are rare and are not discussed further in this document. Total mastectomy: removal of the breast tissue and nippleareola complex, typically used as one type of treatment for DCIS. Ultrasonography: imaging method using high-frequency sound waves to diagnose whether masses are solid or fluid-filled

IV.

ASSESSMENT

DEMOGRAPHIC DATA Name: Jane Doe Gender: Female Civil Status: Married Address: Barangay 1, Malaybalay City, Bukidnon Birthday: February 5, 1952 Place of birth: Medina, Misamis Oriental Age: 60 years old Weight: 74 kg. Religion: Roman Catholic Occupation: Medical Technologist Monthly income: P50,000 P60,000 Admitting Diagnosis: Breast Cancer, left, Stage IIIB Date of Admission: June 27, 2012 Time: 1:25 pm Date of Discharge: July 3, 2012

HISTORY OF PAST ILLNESS The patient has asthma but she no longer had an attack for almost two years from now. Her medication for previous attacks was Ventulin. She doesnt smoke nor drink alcohol. Jane Doe also prefers to eat meat as her viand most of the time and seldom does she eat vegetables. She also proclaims no history of hypertension and diabetes. She gave birth to her youngest child last 1992 via cesarian section because the fetus was already post term. It was found out later during the operation that she also has a myoma and was removed at the same time during the operation.

HISTORY OF PRESENT ILLNESS Jane Doe felt a lump on her left breast on the upper outer quadrant last 2007 but she did not consult a doctor because the lump was just very small and is painless. The breast mass gradually enlarged until pain was noted last 2011. She thought that the pain was triggered when her grand-child has accidentally stepped on her breast while they were playing. She sought advice from Bukidnon Provincial Medical Center. She has undergone a Fine Needle Aspiration Biopsy twice. The results were all negative for malignancy. She was told that the lump was just benign. However, she was not satisfied with the result because she noticed that the lump was getting bigger. At first, there were no discharges. But, after having two FNABs, discharges were already oozing out of the site. Then she also noticed that the pores on her left breast resembled that of an orange peel (peau d orange). She sought advice from Dr. Melicor of Bethel Baptist Hospital. She was advised to have another Fine Needle Aspiration Biopsy for the third time last January 2012. She consented. This time the result was that she was positive for Breast Cancer Stage III B at the left breast. She was advised for neoadjuvant chemotherapy. She agreed to have the treatment at Bethel Baptist Hospital. She started the first chemotherapy last January 9, 2012. Her medications were as follows: Ondasetron and Dexamethasone, 8 mg. IVTT, thirty minutes before chemotherapy; 5FU (Fluorouracil) 900 mg. IVTT and Doxorubicin 90 mg., IVTT administered at 3 5 minutes; cyclophosphamide 900 mg. in 200ml D5W x 1 hours; Advance Omega, 1 tablet each

day for 60 days. She has succeeding sessions of chemotherapy last February 4, 2012; March 3, 2012; April 28, 2012; and May 26, 2012. She was advised for Modified Radical Mastectomy thus she sought admission on June 27, 2012.

POST-OPERATIVE ASSESSMENT (four-day post-op) July 2, 2012 General health Survey 60 year-old fairskinned, pale woman Awake, alert, oriented, with memory intact. Appearance consistent with stated age. Vital signs: BP- 120/90, T- 37.1C, P- 86bpm, R- 19cpm

I. Integumentary System A. Skin

Color pallor Lesions none Wound surgical wound d/t modified radical mastectomy of the left breast. Progressive wound healing noted. Drainage serousanguinous discharges on both the 2 jackson pratt drainage Temperature 37.1C Moisture decreased moisture due to increased age Turgor less skin turgor due to increased age Subjective Data: Nanglagum akong kamot ug kuko tungod sa akong pagpachemotherapy, as verbalized by the patient B. Nails Color pale with dark longitudinal ridges Capillary refill normal (3-5 seconds)

C. Hair Hair distribution thin hair due to chemotherapy. Patient has eyelashes but no eyebrows. Color gray hair Body hair none Condition of scalp scalp intact with no signs of tenderness or pediculosis Nursing Diagnosis: 1. Impaired tissue Integrity related to effects of chemotherapy and surgery. 2. Risk for infection related to inadequate immune defenses due to invasive procedure (mastectomy) and use of immunosuppressive drugs (Dexamethasone)

I. Head

HEENT

Facial movement symmetrical No tenderness or lesions Relatively smooth with no unexpected contours or bulges Eyes Patient usually wears eyeglasses with 2.75 diopter prescription. This means that the patient has moderate hyperopia (farsightedness). Upon admission, patient did not wear the prescribed eyeglasses. Conjunctiva pale and dry. No discharges. Palpebral fissures equal. No lid lag Ears Hearing intact No drainage and bleeding Nose

Midline placement. Shape symmetrical. No nasal flaring No drainage Neck No neck vein distention No palpable or visible lymph nodes

Lips Midline intact, symmetrical, pale and dry Mouth and Throat Number of teeth: 2 Mucosa intact, pale and has no lesions Tongue pale, pink, and dry.

Nursing Diagnosis: 1. Risk for impaired oral mucous membrane related to side effects of some chemotherapeutic agents. 2. Risk for injury related to visual impairment (farsightedness).

II.

Breast Large, pendulous right breast, soft, nontender Left breast removed with axillary fat pads and some pectoralis major muscle.

Subjective Data: Nagbasul gyud ko na wala dayon ko nagpatambal sa una, as verbalized by the patient. A. Nipples and Areola (Right breast)

Color darker than breast tissue Everted

B. Axilla No lesions or thickening noted on the right axilla. Left axilla covered with a clean dressing. No purulent odor noted. Serousanguinous drainage noted on Jackson pratt attached at left midaxillary line measuring 130 cc on tube 1 and 2 cc on tube 2. Nursing Diagnosis: 1. Disturbed body image related to changes in breast and sexuality.

III. Nutrition and Elimination Number of teeth: 2 Weight 74 kg BMI 30.5

Body type - endomorph Usual Diet Rice, more on meat for three times a day. Upon assessment, patients foods are being blenderized in order for her to swallow and digest the foods easily. Number of fluid each day- estimated to be 2-5 glasses a day. Subjective Data: Ayha ra ko gainum kung uhawon na ko or magsakit na ako bat-ang, as verbalized by the patient. No IVF attached Bowel Movement once a week (before admission and if patient is working). On days when she stays at home, she defecates once every two days. Food restrictions R/T intolerance and health problems: Meat, milk, fatty foods, coffee, yogurt, raw fishes (kinilaw), shrimp, sweets, dairy products, salty foods, oily foods, acidic foods (patient experiences hyperacidity). Loss of appetite noted, previously experienced nausea and vomiting but was already relieved upon this days assessment.

Hours of sleep: 8 hours of frequently interrupted sleep (in the hospital) Intake (oral fluids) 840cc (for 7-3 shift) Output - (for 7-3 shift) Urine 930cc Jackson Pratt 130cc (1), 2cc (2) Medications: Antibiotics, Analgesics, Loop Diuretic ( Furosemide), Proton Pump Inhibitor (Pantoprazole), Anti-fibrinolytic (Vit.K), GI stimulant (Metronidazole), Narcotic Agonist. Nursing Diagnosis: 1. Imbalanced Nutrition less than Body Requirements related to side effects of chemotherapy. 2. Constipation related to poor fluid intake, low bulk diet, lack of exercise, use of narcotics (Oxynorm), and irritation of GI mucosa from chemotherapy. 3. Fluid volume deficit related to decreased fluid intake and presence of abnormal routes (Jackson pratt drainage on left mid-axillary line)

IV. Respiratory System RR: 19cpm History of medical problems: asthma (last attack-two years ago) Medication: Ventolin (for previous attacks) Sensitivity to: pollen and cold temperature. When she is exposed to any of these, she experiences non-productive cough which turns into productive cough after two to three days. Occupation: As a medical technologist, she mostly spends her time at work in various barangays and towns wherever they were assigned for almost thirty years. She verbalized that she might be exposed to respiratory irritants at work which may have triggered her previous asthma attack. After being diagnosed with Breast Cancer Stage IIIB, she still worked but in an office instead of being on a field. Breath Sounds: Normal and not labored

No cough noted. Nursing Diagnosis: None

V. Cardiovascular System BP 120/90 mmHg PR- 86 bpm Family History: No known family history of hypertension, stroke, and diabetes Patient denies feeling chest pains, palpitations, syncope, dyspnea and cough. Bipedal edema ( pitting, grade 1) secondary to fluid retention due to blood transfusion, noted three days post-operative. Upon this days assessment bipedal edema has already been corrected. Heart sounds: Normal (S1 and S2) Heart Rhythm: Regular Jugular Vein Distention: negative Nail beds: Pale pink Capillary Refill: Normal Nursing Diagnosis: None

VI. Musculoskeletal System Mobility ambulatory and able to perform ADLs Gait and Posture: Senile kyphosis Muscle tone or Strength: able to tolerate ROM Denies feeling of pain due to the effects of analgesics ( Parecoxib and Efercoxib) using the PCA Complains of fatigue and interrupted sleep because of frequent monitoring by the staff nurses.

Exercise: ROM as ordered post-operatively. Frequency: as often as tolerated. Nursing Diagnosis: 1. Fatigue related to altered body chemistry secondary to side effects of chemotherapy.

V.

ANATOMY AND PHYSIOLOGY

Mammary Glands In males and females, the breasts are the same until puberty, when estrogen and other hormones initiate breast development in females. This development usually occurs at about age 10 years and continues until about age 16 years, although the range can vary from 9 to 18 years. Stages of breast development are described as Tanner stages 1 through 5. Stage 1 describes a prepubertal breast. Stage 2 is breast budding, the first sign of puberty in a female. Stage 3 involves further enlargement of breast tissue and the areola (a darker tissue ring around the nipple), and stage 4 occurs when the nipple and areola form a secondary mound on top of the breast tissue. Stage 5 is the continued development of a larger breast with a single contour.

The breast contains glandular (parenchyma) and ductal tissue, along with fibrous tissue that binds the lobes together and fatty tissue in and between the lobes. These paired mammary glands are located between the second and sixth ribs over the pectoralis major muscle from the sternum to the midaxillary line. An area of breast tissue, called the tail of Spence, extends into the axilla. Coopers ligaments, which are fascial bands, support the breast on the chest wall. Each breast consists of 12 to 20 cone-shaped lobes that are made up of lobules containing clusters of acini, small structures ending in a duct. All of the ducts in each lobule empty into an ampulla, which then opens onto the nipple after narrowing. About 85% of the breast is fat. The female breast is made up mainly of lobules (milk-producing glands), ducts (tiny tubes that carry the milk form the lobules to the nipple), and stroma (fatty tissue and connective tissue surrounding the ducts and lobules, blood vessels, and lymphatic vessels). Most breast cancers begin in the cells that line the ducts (ductal cancers). Some begin in the cells that line the lobules (lobular cancers), while a small number start in other tissues.

The Lymphatic System

The lymph system is important to understand because it is one of the ways in which breast cancers can spread. This system has several parts: Lymph nodes - are small, bean-shaped collections of immune cells (cells that are important in fighting infections) that are connected by lymphatic vessels. Lymphatic vessels are like small veins, except that they carry a clear fluid called lymph (instead of blood) away from the breast. Lymph contains tissue fluid and waste products, as well as immune system cells.

Breast cancer cells can enter lymphatic vessels and begin to grow in lymph nodes. Most lymphatic vessels in the breast connect to lymph nodes under the arm (axillary nodes). Some lymphatic vessels connect to lymph nodes inside the chest (internal mammary nodes) and those either above or below the collarbone (supraclavicular or infraclavicular nodes). Knowing if the cancer cells have spread lymph node is important because if it has, there is a higher chance that the cells could have also gotten into the bloodstream and spread (metastasized) to other sites in the body. The more lymph nodes that have breast cancer, the more likely it is that the cancer may be found in other organs as well. This is important to know because it could affect your treatment plan. Still, not all women with cancer cells in lymph nodes develop metastases, and in some cases a woman can have negative lymph nodes and later develop metastases. Fibrocystic Changes Most lumps turn to be fibrocystic changes. The term fibrocystic refers to fibrosis and cysts. Fibrosis is the formation of fibrous (scar-like) tissue, and cysts are fluid-filled sacs. Fibrocystic changes can cause breast swelling pain. This often happens just before a womans menstrual period is about to begin. Her breasts may feel lumpy and, sometimes, she may notice a clear or slightly cloudy nipple discharge.

VI.

PATHOPHYSIOLOGY

Breast cancer is a cancer that starts in the breast, usually in the inner lining of the milk ducts or lobules. Predisposing factors Gender female Age 60 years old Benign breast conditions Dense breast tissue Late menopause 58 years old Early menarche Family history of breast cancer Personal History of breast cancer Lobular carcinoma in situ Diethylstilbestrol exposure Precipitating Factors Oral contraceptive use Not breastfeeding Overweight Diet more on meat Having children Stress Hormone therapy after menopause Alcohol use Tobacco smoke Tight fitting bras Breast implants

Normal Cell Proliferation

Somatic mutations in the

DNA

Activate Oncogenes

Deactivate tumor suppressor genes

Alteration in genes that requires apoptosis

Unregulated cell proliferation

Formation of primary tumors

Cross talk between cancer cells and host stromal cells

Cancer cells remain inside the breast duct w/o invasion into normal adjacent breast tissue

S/S Lump or mass in the breast (First sign) painless, hard, uneven edges

Tumor progression

Tumor cells can either directly secrete angiogenic substance or release/activate them from ECM

Angiogenesis

Tumor cells and invading mononuclear cells from host produce degradative enzymes w/c facilitate invasion of the stroma

Tumor cells downregulate adhesion molecules ( e.g Ecadherin)

Invasion: thin-walled vessels easily penetrated

Cancer cells invade nearby healthy breast tissues

Axillary lymph nodes and lymph nodes near the breast bone becomes affected

Inflammatory breast cancer

S/S Reddening of a large portion of the breast breast feels warm, swollen and tender peu d orange

Metastasis to other body organs

Functions of the organ involved deteriorates

Death

Legend: Patient-based Book-based Signs and Symptoms VII. Manifested by the patient ACTUAL TREATMENT UTILIZED

Laboratory and Diagnostic Examinations Date Laboratory and Ordered Diagnostic Exam 02/3/20 CBC: 12 WBC RBC Hgb Result Normal Range Significance

8.2 x103/uL 4.04 x106/uL 11.9 g/dL

4.5-10.5 x103/uL 4.00-6.00 x106/uL 12.0-16.0 g/dL

Hct MCV MCH MCHC LY% LY# Differential Count: Lymphocytes Segmenters Monocytes Eosinophils CBC: WBC RBC

39 % 96.4 fl 29.4 pg 30.5 g/UL 33.1 % 2.7 x103/uL 31 62 6 1 8.0 x103/uL 3.86 x106/uL

36.0-48.0% 80.0-99.9 fl 27.0-31.0 pg 33.0-37.0 g/UL 20.5-51.1% 1.2-3.4% 25-40% 50-62% 3-7% 0-3% 4.5-10.5 x103/uL 4.00-6.00 x106/uL

Within normal limits Within normal limits Slightly decreased: May be because of Chemotherapy treatment wherein there is anemia present Within normal limits Within normal limits Within normal limits Decreased: -indicative of anemia Within normal limits Within normal limits Within normal limits Within normal limits Within normal limits Within normal limits

03/29/2 012

Within normal limits

Hgb Hct MCV MCH MCHC LY% LY# Differential Count: Lymphocytes Segmenters Eosinophil Electrolytes: K+ Na+ ClLiver Profile: SGPT Protime: Patient INR Clinical Chem. Glucose Uric Acid

11.5 g/dL 37.4% 96.7 fl 29.8 pg 30.8 g/dL 27.1% 2.2 x103/uL 25 73 2

12.0-16.0 g/dL 36.0-48.0% 80.0-99.9 fl 27.0-31.0 pg 33.0-37.0 g/UL 20.5-51.1% 1.2-3.4% 25-40% 50-62% 0-3%

Within normal limits Within normal limits Within normal limits Within normal limits Decreased: -indicative of anemia Within normal limits Within normal limits Within normal limits Within normal limits Within normal limits

6/21/20 12

4.57 144.5 mEq/L 110.0 mEq/L 46 U/L

3.5-5.5 mEq/L 135-145 mEq/L 96-110 mEq/L 7-35 U/L

Within Normal Limits Within Normal Limits -dehydration -increased cancer due to

15.4 sec 1.16

11.0-13.0 sec 0.8-1.2

Prolonged -vitamin K deficiency Prolonged: -vitamin K deficiency Within normal limits

105.29 mg/dL 6.49 mg/dL

80-120 mg/dL 2.4-6.0 mg/dL

Creatinine Cholesterol

1.63 206.4

HDL Cholesterol Triglyceride

47.1mg/dL 145.9 mg/dL

LDL 120mg/dL % HDL of total 22.81%

Elevated in hyperlipidemia, obesity 0.6-1.1 mg/dL Slightly elevated: Borderline high levels: diet high in cholesterol and fats Women: 35-65 Within normal limits mg/dL Desirable: Borderline high: diet <150 mg/dL high in cholesterol Borderline high: and fat 150-200 mg/dL High: 200-499 mg/dL <130 mg/dL Desirable 10-30% Within normal limits

cholesterol U/A: Color Transparency pH Specific Gravity WBC RBC Epithelial cells Bacteria CBC: WBC RBC Hgb Hct MCV MCH MCHC LY% LY# Differential Count: Lymphocytes Segmenters Platelet 6/27/12 6/28/20 12 Blood Typing Blood TypeDonor BPH-12190 Hgb

Yellow Hazy 5.0 1.005 4-6/hpm 0-2/hpm Occasional Moderate 5.3x103/uL 4.15x103/uL 12.3 g/dL 40.4% 97.5 fl 29.8 pg 30.5 L g/dL 30.9% 1.6x103/uL 31 69 318,000

Pale yellow to amber 4.6-8.0 1.005-1.030 0-6/hpm 0-2/hpm occasional 4.5-10.5 x103/uL 4.00-6.00 x106/uL 12.0-16.0 g/dL 36.0-48.0% 80.0-99.9 fl 27.0-31.0 pg 33.0-37.0 g/UL 20.5-51.1% 1.2-3.4% 25-40% 50-62% 150,000400,000/uL

Within normal limits Within normal limits Within normal limits Within normal limits Within normal limits Within normal limits Within normal limits Within normal limits Within normal limits Within normal limits Within normal limits Within normal limits Within normal limits Within normal limits Decreased: -indicative of anemia Within normal limits Within normal limits Within normal limits Slightly elevated Within normal limits

6/30/20 12

O positive Blood Type Group O+ RH+ Compatible 9.2 g/dl 12.0-16.0 g/dL

Blood can transfused to patient

be the

Hct

29.6 %

36.0-48.0%

Decreased due to recent blood loss from operation Decreased due to recent blood loss from operation Within normal limits Decreased: may be indicative of anemia Slightly decreased Within normal limits Increased: indicative

07/1/12

CBC: WBC RBC Hgb Hct MCV

8.2 x 103/uL 3.71L x 3 10 /uL 11.3 g/dL 37.9% 102.0 Hfl

4.5-10.5 x103/uL 4.00-6.00 x106/uL 12.0-16.0 g/dL 36.0-48.0% 80.0-99.9 fl

of macrocytic anemia because neoplastic diseases increased requirements of oxygen MCH MCHC Differential Count: Lymphocytes Segmenters Monocyte Eosinophil 30.3 pf 29.7 L g/UL 27.0-31.0 pg 33.0-37.0 g/UL Within normal limits Decreased: -indicative of anemia Within normal limits Within normal limits Within normal limits Elevated: solid tumors neoplasms is most likely to provoke eosinophilia

30 56 3 11

25-40% 50-62 3-7 0-3

Cardiac Pulmonary Clearance Risk Factors 1. History Age: > 70 yr. MI within previous 6 mos, unstable angina w/in 3 mos or chronic stable angina with CCS class III or IV angina 2. Physical Examination S3 gallop or jugular vein distention, decompensated CHF Severe aortic stenosis or mitral stenosis 3. ECG Rhythm other than sinus or PACs on last pre-op ECG More than 5 PVCs/min documented at any time before operation 4. General Status PO2 <60 or PCO >50mmHg, J <3 (or HCO3 <20 mEq/L, BUN>50 or Crea >3.0 mg/dl, abnormal SGOT, signs of chronic liver disease, or pt. bedridden from non-cardiac causes Points 5 10 Pt. Points 0 0

11 3 7 7

0 0 0 0

5. Operation Intraperitoneal, intrathoracic or aortic operation Emergency operation TOTAL:

3 4 53

0 0 0

Goldmans class Class Class I Class II Class III Class IV Points Incident of threatening 0-5 pt. (Low risk) 1-27% 6-12 pt. (Intermediate 5-7% risk) 13-25 pt (Intermediate 16% risk) >26 pt (High risk) 56% Life

Surgical Pathology Report Final Pathological Report: July 10,2012 Breast, Left, Modified Radical Mastectomy Invasive Ductal Carcinoma, Nottingham Histologic Grade 2 Tumor Size: 3.5 cm No lymphovascular invasion noted Nipple, resection margins, ten axillary nodes, (-) for tumor

GROSS/MICROSCOPIC DESCRIPTION: Received 2 specimens: A. Specimen consists of the left breast and its axillary fat pad. The breast measures 26x19x17 cm. The axillary fat pad measures 6 cm. The skin ellipse measures 21x16cm. The areola and nipple each measures 4x3cm and 1.1x1cm. There is a grayish tan irregular nodulation on the skin, 5x4 cm located 3 cm from the areola, outer mid quadrant. Cut section shows a cystic mass, 6x5 cm filled with reddish brown fluid, & near the cyst cavity is an ill defined tan firm mass, 3.5x2 cm located 11.8,6,9.9 5 and 2 cms from the superior, inferior, medial, lateral and basal resection margins. Six nodes were harvested from the axillary fat, 0.3-0.4 cm

B. Specimen consists of few irregular gragments of yellowish brown soft tissues measuring 6.1 cm. Block all. Microscopic Description: Microsection show breast tissues. These are tumor cells, in nests and clusters. The tumor cells show hyperchromatic nuclei, scanty cytoplasm, with occasional cells seen exhibiting promineral nucleoli. There is stromal desmoplasia. Surrounding these tumor cells are fibrous areas with histiocytes and hemosicclear laden macrophages. The nodes show reactive hyperplasia. July 03, 2012 Immunohistochemistry Report Exam: Estrogen Receptor Assay, Progesterone Required: Receptor assay Specimen: Paraffin Block, Breast Estrogen Receptor Staining Intensity: +2 % Tumor cells stained: +4 Progesterone Receptor: Staining Intensity: +3 % Tumor cells stained: +4 Paraffin sections of tumor were processed through antigen retrieval technique and immunostained for estrogen, progesterone receptors. (+) results how nuclear or nuclear & cytoplasmic staining. Patients with ER PR (+) breast tumors have systemic disease free intervals of 68% and overall 5 year survival rate of 88% 0=1-10% +2=26-50% +4=>75% +1=11-25% +3=51-75% September 10, 2012 Lumbosacral Spine Findings: History: Post-Chemo There is no evidence of bone involvement Intervertebral disc spaces are Pedicles & posterior vertebral elements are intact

Included pelvis is unremarkable Impression/s: No significant findings in these exam

ACTUAL DRUG STUDY (PRE-OP DRUGS) Name of drug (brandname) Pantoprazol e Classificatio n Proton Pump Inhibitor Dose/ Route 40mg 2 tabs Mechanisms of Action Proton pump Inhibitors act at specific secretory surface receptors to prevent the final step of acid production and thereby decrease the level of acid in the stomach. Indication Contraindication Adverse effects Nursing Precautions

Given as prophylaxis

These drugs are contraindicated in the presence of known allergy to either the drug or the drug components. Caution should be used in pregnant or lactating women.

CNS: dizziness, headache, asthenia (loss of strength), vertigo, insomnia, apathy. GI: diarrhea, abdominal pain, nausea, vomiting, dry mouth, tongue atrophy. URT: cough, stuffy nose, hoarseness, epistaxis. Others: rash, alopecia, pruritus, dry skin, back pain, fever.

Assessment: History and Examination. Screen for any history to a proton pump inhibitor, pregnancy, or lactation. Include screening to establish baseline data for assessing the effectiveness of the drug and the occurrence of any adverse effects associated with drug therapy. Assess skin color and lesions as well as reflexes, affect and orientation. In addition, perform an abdominal and respiratory examination.

Name of drug (brandname) Cefazolin

Classification Firstgeneration cephalospori ns

Dose/Ro ute 2grams IV ANST on call to OR

Mechanisms of Action The cephalosporins are both bactericidal and bacteriostatic, depending on the dose used and the specific drug involved. In susceptible species, these agents basically interfere with the cell wall-building ability of bacteria when they divide. That is, they prevent the bacteria from biosynthesizing the framework of their cell walls. The bacteria with weakened cell walls swell and burst as a result of osmotic pressure within the cell.

Indication Contraindic ation As These prophylax drugs is to should not prevent be used in infection patients after with known surgery allergies to cephalospor ins or penicillins, because crosssensitivity is common. In addition, caution must be used in patients with renal failure.

Adverse effects

Nursing Precautions GI: nausea, vomiting, Assessment: diarrhea, anorexia, History and abdominal pain, and examination flatulence (common). Screen for known Pseudomembranous allergy to colitis, a potentially cephalosporin, dangerous disorder, has penicillin, or any also been reported with other allergens; some cephalosporins. A history of renal particular drug should be disease; and discontinued current pregnancy immediately at any sign and lactation of violent, bloody status diarrhea or abdominal Examine skin for pain. any rash or CNS: headache, lesions. Note for dizziness, lethargy, respiratory statusparesthesias. including, rate, Nephrotoxicity is also depth adventitious associated with the use sounds. of cephalosporins, most Check renal particularly in patients function test who have a predisposing results, including renal insufficiency. Other BUN and adverse effects include creatinine superinfections. clearance. Monitor hepatic function.

Name of drug (brandname) Ampicillinsulbactam

Classification Penicillins and penicillinaseresistant antibiotics

Dose/Rout e 1.5grams IV ANST on call to OR

Mechanisms of Action The penicillin and penicillinaseresistant antibiotics produce bactericidal effects by interfering with the ability of susceptible bacteria to build their cell walls when they are deviding. These drugs prevent the bacteria from biosynthesizing the framework of the cell wall, and the bacteria with weakened cell walls swell and then burst from osmotic pressure within the cell. Because human cells do not use the biochemical process that the bacteria use to form the cell wall, this effect is a selective toxicity.

Indication Prophylaxi s for patients undergoing surgery.

Contraindication Contraindicated in patients with allergies to penicillin, cephalosporins, or other allergens. Penicillin sensitivity tests are available if the patients history of allergy is unclear and penicillin is the drug of choice. Caution should be exercised in patients with renal disease. In those who are pregnant and in lactating women (diarrhea and superinfections may occur in the infant.

Adverse effects

Nursing Precautions GI: nausea, Assessment: vomiting, history and diarrhea, examination abdominal Screen for any pain, glossitis, known allergy to stomatitis, these drugs; gastritis, sore history of renal mouth, and disease;current furry tongue. pregnancy or Superinfection, lactation status. including yeast examine the skin infections. and mucous Hypersensitivity membrane for any reactions may rashes or lesions. include rash, Note for fever, wheezing respiratory status and with to provide baseline repeated for the occurrence exposure, of hypersensitivity anaphylaxis reactions. that can Examine the progress to abdomen for anaphylactic adverse effects. shock and Evaluate renal death. function test findings including BUN and creatinine clearance.

Name of drug (brandname) Vitamin K

Classification Dose/Route Antifibrinolyti c agent; fat soluble vitamin 1 tab now TID

Mechanisms of Action Vitamin K controls the clotting mechanism of the blood because its action is directed at the precursor of prothrombin. Prothrombin is activated to form thrombin, an enzyme which, in turn, converts fibrinogen to fibrin, the insoluble protein that solidifies the blood clot.

Indication Needed for the production of prothrombin (blood clotting) Antibiotics interfere with absorption of vitamin K.

Contraindicatio n Contraindicated in the presence of known allergy to the drug. Not be used with any conditions that could compromised by increased bleeding tendencies, including hemorrhagic disorders, recent trauma, spinal puncture, GI ulcers, recent surgery, in pregnancy, renal or hepatic disease. Caution should be used in patients with congestive heart failure (CHF), and with diarrhea or fever.

Adverse effects Bleeding, ranging from bleeding gums with tooth brushing to severe internal hemorrhage. Clotting times should be monitored closely to avoid these problems. Nausea, vomiting. Diarrhea, hepatic dysfunction. Warfarin has been associated with alopecia, and dermatitis as well as bone marrow depression

Nursing Precautions Assessment: history and examination Screen for known allergies to these drugs. screen for conditions that could exacerbated by increased bleeding tendencies, including hemorrhagic disorders, recent trauma, spinal puncture, GI ulcers, recent surgery, in pregnancy, renal or hepatic disease, or with CHF, diarrhea or fever. Assess for the following: clotting studies, renal and hepatic function test, ECG.

(POST OPERATIVE DRUGS) Name of Classification Dose/Route drug (brandname) Furosemide Loop 40mg 1 tab diuretics. Mechanisms of Action Loop diuretics are also referred to as High-ceiling diuretics because they cause a greater degree of diuretics than other diuretics. These drugs block the chloride pump in the ascending loop henle, were normally 30% of all filtered sodium is reabsorbed. This action decreases the reabsorption of sodium and chloride. Indication Contraindica tion Never use with ethacrynic acid. Anuria, hypersensitiv ity to drug, severe renal disease associated with azotemia and oliguria, hepatic coma associated with electrolyte depletion. lactation. Adverse effects Jaundice, Nursing Precautions

Indicated to treat bipedal edema

Furosemide is a potent diuretic. Excess tinnitus, amounts can hearing lead to impairment, profound dieresis with hypotension, water and electrolyte pancreatitis, depletion. Careful medical attention is abdominal needed; pain, individualize dosage. Dizziness, anemia. Geriatric clients may be more sensitive to the usual adult dose. Allergic reactions may be seen in clients who show hypersensitivity to sulfonamides.

Name of drug Parecoxib

Classificati on Nonsteroidal antiinflammat ory drugs

Dose/Ro ute 40 mg IVTT q8o

Mechanisms of Action NSAIDs inhibit cyclooxygen ase (COX) enzymes, which are involved in the synthesis of prostaglandins and thereby reduce pain and inflammation. Oral NSAIDs are used postoperatively but when patients are unable to tolerate oral medications or required faster onset of analgesia, parenteral administ ration may be preferred.

Indication

Contraindicati on Indicated kidney or for the liver disease short-term heart treatment problems, of postoper heart surgery, ative pain or other in adults. blood vessel disease diabetes high cholesterol

Adverse effects changes in blood pressur e dizziness or lightheadedness due to low blood pressure stomach upset includin g nausea(feeling sick), vomiting, heartburn, indigestion, cramps

Nursing Precautions Assess for the level of infection at the beginning at throughout the administration of the medication Obtain specimen for culture and sensitivity before initiating therapy 1dose may be given even without the results Monitor intake and output and daily weight to assess hydration status and renal function Assess for the patients signs and symptoms of superinfection,

report to the physician early if it occur Resolution of signs and symptoms of superinfection if it occurs and if no responses seen within 3-5 days, new cultures should be taken

Name of Classification Dose/Route drug (brandname) Oxynorm Narcotics 5mg agonist capsule

Mechanism of action The narcotic agonist act at specific opioid receptor site in the CNS to produce analgesia, sedation and a sense of well-being. They are used as antitussives and as adjuncts to general anesthesia to produce rapid analgesia, sedation, and respiratory depression.

Indication

Contraindication Side effects Patients with known hypersensitivity to oxycodone or any of the other ingredients, This includes patients with respiratory depression, paralytic ileus, acute abdomen, chronic obstructive airways disease, cor pulmonale, chronic bronchial asthma, hypercarbia, moderate to severe hepatic impairment, severe renal impairment (CrCl <10 mL/min), chronic constipation, skin rash, itching, chills or fever sweating unusual weakness or loss of strength

Nursing precautions
Caution in the following conditions: acute alcoholism; adrenocortical insufficiency (e.g., Addison's disease); convulsive disorders; CNS depression or coma; delirium tremens; debilitated patients; kyphoscoliosis associated with respiratory depression; myxedema or hypothyroidism; prostatic hypertrophy or urethral stricture; severe impairment of hepatic, pulmonary or renal function; and toxic psychosis.

Treatment of moderate to severe pain in patients with cancer and postoperative pain.

Name of drug (brandname ) Etoricoxib (arcoxia)

Classification

Dose/Route

Mechanism of action

Indication

Contraindication

Adverse effects

Nursing precautions

COX-2 selective inhibitor

90mg 1 tab

Like any other COX-2 selective inhibitor Arcoxia selectively inhibits isoform 2 of cyclooxigenase enzyme (COX-2). This reduces prostaglandins (PGs) generation from arachidonic acid.

Relief of chronic musculosk eletal pain and acute pain

Patients with hypersensitivity to any component of Arcoxia, congestive heart failure (NYHA IIIV); established ischemic heart disease, peripheral arterial disease and/or cerebrovascular disease (including patients who have recently undergone coronary artery bypass graft (CABG) surgery or angioplasty).

feeling sick (nausea), vomiting heartburn, indigestion, uncomforta ble feeling or pain in the stomach diarrhea swelling of the legs, ankles or feet high blood pressure dizziness headache taste alteration wheezing insomnia anxiety drowsiness

Caution should be used when initiating treatment with Arcoxia in patients with considerabl e dehydration . It is advisable to rehydrate patients prior to starting therapy with Arcoxia Patients with renal disease

Name of drug (brandname) Metocloprami de (plasil)

Classificati on Antiemetics

Dose/Rout e 1 amp IV q6

Mechanism of action It blocks dopamine receptors and makes the GI cells more sensitive to acetylcholin e, leading to increased GI activity and rapid movement of food through the upper GI tract.

Indication Prevention of chemotherap y-induced emesis, Treatment of postsurgical and facilitation of small bowel intubations in radiographic procedures,

Contraindicati on Known allergy to the antibiotic or related antibiotics and during pregnancy and lactation.

Adverse effects

Care should also be done in patients with conditions: Management bone marrow of suppression, esophageal suppressed reflux, renal or treatment hepatic and function, GI prevention of ulcerations or postoperative ulcerative nausea and disease, vomiting pulmonary when problems with nasogastric bleomycin or suctioning is mitomycin, undesirable cardiac problems with idarubicin or mitoxantrone, and bleeding

Nursing precautions Bone marrow Assess suppression, mental with leucopenia, status during thrombocytopeni treatment a, anemia, and pancytopenia. Assess patient for Nausea, nausea, vomiting, vomiting, anorexia, abdominal diarrhea, and distention, mucous and bowel membrane sounds deterioration. before and after Renal or hepatic administratio toxicity alopecia. n. May cause drowsiness. Advise patient to avoid concurrent use of alcohol and other CNS depressant while taking this medication.

disorders with plicamycin. Which are specifically toxic to these systems.

Name of Classification Dose/Route drug (brandname) Dulcolax Laxatives 2 tabs (Bisacodyl) tonight if unable to defecate today

Mechanism of action Laxatives work in 3 ways 1. by direct chemical stimulation of the GI tract 2. by production of bulk or increase fluid in the lumen of the GI tract, leading to stimulation of local nerve receptor or 3. by lubrication of the intestinal bolus to promote passage through the GI tract.

Indication

Contraindication Adverse effects Laxative are contraindicated in acute abdominal disorders, including appendicitis, diverticulitis, and ulcerative colitis, when increase motility could lead to rupture or further exacerbation of inflammation. It should be used with caution during pregnancy and lactation. Diarrhea

Nursing precautions

Short-term relief of constipation ; to prevent straining when it is clinically undesirable (such as after surgery)

Screen for the following Abdominal conditions, cramping, which could be cautions or nausea, contraindications to be used of the dizziness, drugs: history of allergy to headache, laxatives, fecal impaction, weakness, intestinal obstruction, semi sweating colon, acute abdominal pain, palpitations, nausea, vomiting. flushing, and even Includes fainting screening presence of skin lesions base line pulse, abdominal examination including bowel sounds and serum electrolytes.

Name of drug Bactroban Ointment (mupirocin ointment)

Classification Dose/route Antibiotic , topical Cream #1, topical

Mechanism of action Binds to bacterial isoluecyl transfer RNA synthetase, which results in inhibition of protein synthesis by the organism. Not absorbed into the systemic circulation. Serum present in exudative wounds decreases the antibacterial activity.

Indication Secondarily infected traumatic skin lesions

Contraindication Side effects Hypersensitivity Rash to any component of Burning at the product. application site Should not be Cellulitis used for general prophylaxis of Dermatitis any infection. Pruritus

Nursing precautions Use aseptic measures and hand washing before and after therapy to prevent contamination. Report any symptoms of chemical irritation or hypersensitivity such as increased rash, itching, pain at site or lack of healing.

Name of the drug (Brandname ) Coamoxiclav (Amoclav)

Classification

Dose /route

Mechanism of Indications action

Contraindications

Side effects

Nursing precautions

Penicillin , Bactericidal

625m g

Inhibits enzymes involved information of peptidoglycan layer of bacterial cell wall. No effect on human cell walls Bactericidal; only works on dividing bacteria. Well absorbed enterally Clavulanic acid inhibits bacterial -lactamase

Skin & soft tissue infections Pre& postsurgical proced ures

History of penicillin hypersensitivity. Superinfections involving Pseudomonas or candida. Pregnancy& lactation Decreased liver and urinary function.

Indigestio n Dizziness Headache Rash or hives Itching Nausea. Vomiting Diarrhea

History of hypersensitivit y Renal impairment Hepatic impairment may cause cholestatic jaundice up to 6 weeks after cessation May cause maculopapular rashes almost always in presence of glandular fever People receving high doses of this medicine, particularly by injection,

should make sure they drink plenty of fluid to reduce the risk of crystals forming in the urine. If in hospital, this fluid may be given via a drip.

MAINTENANCE Name of Classification Dose/Route Mechanisms of drug Action (brandname) Aromasin aromatase 25mg OD Cell growth may (Arnex) inhibitor PO be estrogendependent. Aromatase is the principal enzyme that converts androgens to estrogens both in pre- and postmenopausal women. While the main source of estrogen (primarily estradiol) is the ovary in premenopausal women, the principal source of circulating estrogens in postmenopausal women is from conversion of adrenal and ovarian androgens (androstenedione and ) to Indication Contraindication Adverse effects Aromasin Tablets are contraindicated in patients with a known hypersensitivity to the drug or to any of the excipients. hot flashes headache depression difficulty in breathing feeling tired trouble sleeping feeling anxious joint pain increased sweating upset stomach Nursing Precautions Aromasin should not be coadministered with estrogencontaining agents as these could interfere with its pharmacologic action. Before using this medication, tell your doctor or pharmacist your medical history, especially of: high blood fats (cholesterol), bone problems (such as osteopenia, osteoporosis), stroke or blood clots, heart disease (such as chest pain, heart attack,

Aromasin is used to treat breast cancer in postmenopausal women.

estrogens (estrone and estradiol) by the aromatase enzyme in peripheral tissues. Estrogen deprivation through aromatase inhibition is an effective and selective treatment for some postmenopausal patients with hormonedependent breast cancer

heart failure), high blood pressure, kidney problems, liver problems. This drug may make you dizzy and tired. Do not drive, use machinery, or do any activity that requires alertness until you are sure you can perform such activities safely. Limit alcoholic.

CHEMOTHERAPY DRUGS NAME OF DRUG Ondansetr on (Zofran) CLASSIFICATI ON Anti-emetics DOSE/ROU TE 8mg, IVTT 30mins MECHANISM OF ACTION Ondansetron antagonises 5HT3 receptor , blocking serotonin, both peripherally on vagal nerve terminals and centrally in the chemorecept or trigger zone. INDICATION CONTRAINDICATI ON Patients with coma or severe CNS depression, or in those who have experienced brain damage or injury, because of the risk of further CNS depression. Severe hypotension or hypertension and severe liver dysfunction, which might interfere with the metabolism of the drug. SIDE EFFECTS NURSING RESPONSIBILITIE S Headache, Monitor malaise/fati patients gue, response to the constipation drug (relief of ; nausea and drowsiness, vomiting) fever, dizziness, Monitor anxiety, adverse effects cold (dizziness, sensation; confusion, GI alterations, cardiac arrhythmias, hypotension)

Used to relive mild nausea and vomiting caused by cancer dru g treatment (chemotherap y) and radiation therapy.

NAME OF DRUG

CLASSIFICA TION

DOSE/R OUTE

MECHANISM OF ACTION

INDICATION

CONTRAIN DICATION

SIDE EFFECTS

NURSING RESPONSIBILIT IES

Dexamethaso ne (Decadron)

Glucocorticoi 8mg, ds IVTT 30mins

Glucocorticid s enter target cells and bind to cytoplasmic receptors, initiating many complex reactions that are responsible for antiinflammatory and immunosuppr essive test. They block the actions of arichidonic acid, which leads to a decrease in the formation of prostaglandin s and leukotrines. Without these chemicals,

Combinatio n with other medications to help prevent nausea and vomiting that can occur as a side effect of chemothera py Short-term treatment of inflammator y disorders.

Allergy to this drug Presence of acute infection Lactation Pregnancy

Increased appetite and weight gain Some patients may experience weight gain due to dexamethasone stimulating the appetite. Fluid retention and swelling in the ankles, feet, hands, or face-This medication can cause bloating in the extremities and the abdominal region. Less commonly, swelling in the chest can cause breathing problems. Indigestion and heartburn -Since dexamethasone can irritate the stomach, patients are advised to take the medication with milk or food. Insomnia- Some people may have trouble falling asleep

For patients with cerebral edema, assess then for level of consciousness changes and headache during the therapy. Instruct patient to avoid people with known infection and contagious illnesses ascorticosteroid s causes immunosuppre ssion and may mask symptoms of infection. Increase dosage when patient is subject to stress.

the normal inflammatory response is blocked.

or may experience disruptions in sleep patterns. Delayed healing of wounds - Bodily wounds that occur from injuries or surgeries may take longer to heal.

Taper doses when discontinuing high-dose or long-term therapy For systemic administration: Do not give drug to nursing mothers; drug is secreted in breast milk.

NAME OF DRUG Advance omega

CLASSIFICA DOSE/ MECHANISM TION ROUTE OF ACTION Vitamin supplement 1 tab OD Promotes proper growth, circulation and healthy brain function.

INDICATIO N Help Reduce Hypertensio n Improve Autoimmun e Diseases

CONTRAI NDICATIO N

SIDE EFFECTS

constipation, dry Anticoagulant mouth, taste perversion, drugs,

Have a bleeding disorder or are Supports the cardiovascula Improve being r and nervous Depression treated systems, for a blood Cancer medical vessels, joint Prevention and cell and Support condition
membrane health, hair, skin, nails and more Easily digestible with no fishy smell and aftertaste, and protects against rancidity. Nutritional cofactors to

depression, dizziness, increased cough, dyspnea, epistaxis,

NURSING RESPONSIBILI TIES Ask patient for allergic to any of its ingredients; or to fish or soy products; or if you have any other allergies Ask patient your medical history, especially of:

bleeding disorder s kidney problem s liver problem s stomach /intestina l problem s (e.g., ulcer, colitis)

help the body absorb fatty acids and support arterial health

NAME OF DRUG 5 FU Flourouracil (Adrucil)

CLASSIFICA DOSE/ MECHANISM TION ROUTE OF ACTION Antimetabolite 900mg, 35mins, IVTT Fluoruracil belongs to the category of chemotherap y called antimetabolit es- It interferes with cells making DNA and RNA, which stops the growth of cancer cells.

INDICATIO N Colon and rectal cancer.

CONTRAI NDICATIO N Poor nutritional state Those with depressed bone marrow function,

SIDE EFFECTS

Diarrhea Nausea and possible occasional vomiting Mouth sores Poor appetite Watery eyes, sensitivity to light(photophobia) Taste changes, metallic taste in mouth during infusion Discoloration along vein through which the medication is given

NURSING RESPONSIBILI TIES Assess patient thoroughly: This can increase your chance of getting an infection May lower your platelet co unt in the weeks after it is given, May cause sores in the mouth or on the lips, which often occur within the first few weeks after starting treatment.

Breast cancer.

Those with Gastrointest potentially serious inal cancers infections or including: anal, esphageal, pancreas and gastric (stomach). Those with a known hypersensi tivity to drug.

Head and neck cancer * Hepatoma (liver cancer).

Low blood counts. Your

Ovarian

cancer.

white and red blood cells and platelets may temporarily decrease. This can put you at increased risk for infection, anemia and/or bleeding.

Topical use (cream or solution) in basal cell cancer of the skin and actinic keratoses. see document Fluorouracil (cream).

Name of drug (brandname) Doxorubicin

Classification

Dose/Rou te 90mg 35minutes IVTT

Mechanisms of Action Doxorubicin is an anthracycline antibiotic that exerts its effects on cancer cells via two different mechanisms. It acts as an intercalating agent and wedges between the DNA bases thus blocking DNA synthesis and transcription. The drug also inhibits the activity of an enzyme, topoisomeras e type II. This leads to breaks in the genomic DNA. Both of these

Indicatio n Indicated to treat breast cancer

Contraindication

Adverse effects Diarrhea hair loss loss of appetite nausea stomach pain Tirednes s

Nursing Precautions Screen for the conditions contraindicated to these drug such as;Baseline neutrophil count <1500 cells/mm3; severe hepatic impairment; recent myocardial infarction; severe myocardial insufficiency; severe arrhythmias; previous treatment with complete cumulative doses of doxorubicin, daunorubicin, idarubicin, and/or other anthracyclines and anthracenedione s. History of

Antineoplasti c, antibiotic

Baseline neutrophil count <1500 cells/mm3; severe hepatic impairment; recent myocardial infarction; severe myocardial insufficiency; severe arrhythmias; previous treatment with complete cumulative doses of doxorubicin, daunorubicin, idarubicin, and/or other anthracyclines and anthracenediones. History of hypersensitivity to conventional or liposomal doxorubicin or their components. Malignant melanoma, cancers of the kidney, large bowel carcinoma, brain tumors and metastases to the CNS.

Weaknes s weight changes

mechanisms result in DNA disruption that ultimately can lead to the death of the cell.

hypersensitivity to conventional or liposomal doxorubicin or their components. Malignant melanoma, cancers of the kidney, large bowel carcinoma, brain tumors and metastases to the CNS.

Name of drug (brandname) Metocloprami de (plasil)

Classificati on Antiemetics

Dose/Rout Mechanism e of action 1 tab It blocks dopamine receptors and makes the GI cells more sensitive to acetylcholin e, leading to increased GI activity and rapid movement of food through the upper GI tract.

Indication Prevention of chemotherap y-induced emesis, Treatment of postsurgical and diabetic gastric stasis, facilitation of small bowel intubations in radiographic procedures,

Contraindicati on Known allergy to the antibiotic or related antibiotics and during pregnancy and lactation.

Adverse effects

Care should also be done in patients with conditions: bone marrow suppression, Management suppressed of renal or esophageal hepatic reflux, function, GI treatment ulcerations or and ulcerative prevention of disease, postoperative pulmonary nausea and problems with vomiting bleomycin or when mitomycin, nasogastric cardiac suctioning is problems with undesirable idarubicin or mitoxantrone, and bleeding

Nursing precautions Bone marrow Assess suppression, mental with leucopenia, status during thrombocytopeni treatment a, anemia, and pancytopenia. Assess patient for Nausea, nausea, vomiting, vomiting, anorexia, abdominal diarrhea, and distention, mucous and bowel membrane sounds deterioration. before and after Renal or hepatic administratio toxicity alopecia. n. May cause drowsiness. Advise patient to avoid concurrent use of alcohol and other CNS depressant while taking this medication.

disorders with plicamycin. Which are specifically toxic to these systems.

VIII.

IDEAL LABORATORY DIAGNOSTIC EXAM

A. Breast Self Examination A breast self exam is when a woman examines her own breasts for changes or problems. Many women feel that doing this is important to their health. It helps them learn how their breasts normally feel, so that if they find a lump they will know if they should call their doctor or nurse. Women older than 20 years should perform monthly breast self-examinations (BSE). If you still have menstrual periods, you should perform the examination a few days after your period has ended. During this time, your breasts are not tender. If you are not menstruating (such as in menopause), BSE should be performed on the same day each month.

. B. Mammograms Mammograms can be used to check for breast cancer in women who have no signs or symptoms of the disease. This type of mammogram is called a screening mammogram. Screening mammograms usually involve two x-ray pictures, or images, of each breast. The x-ray images make it possible to detect tumors that cannot be felt. Screening mammograms can also find microcalcifications (tiny deposits of calcium) that sometimes indicate the presence of breast cancer. Mammograms can also be used to check for breast cancer after a lump or other sign or symptom of the disease has been found. This type of mammogram is called a diagnostic mammogram. Besides a lump, signs of breast cancer can include breast pain, thickening of the skin of the breast, nipple discharge, or a change in breast size or shape; however, these signs may also be signs of benign conditions. A diagnostic mammogram can also be used to evaluate changes found during a screening mammogram or to view

breast tissue when it is difficult to obtain a screening mammogram because of special circumstances, such as the presence of breast implants.

C. Computed Tomography Computed tomography (CT) is a diagnostic procedure that uses special x-ray equipment to obtain cross-sectional pictures of the body. The CT computer displays these pictures as detailed images of organs, bones, and other tissues. This procedure is also called CT scanning, computerized tomography, or computerized axial tomography (CAT). In cancer, CT is used to detect a tumor, provide information about the extent of the disease, help plan treatment, and determine whether the cancer is responding to treatment.

D. Breast ultrasound Ultrasound uses sound waves to produce images of structures deep within the body. Your doctor may recommend an ultrasound to help determine whether a breast abnormality is likely to be a fluid-filled cyst or a solid mass, which may be either benign or cancerous. Breast ultrasound is helpful to guide radiologic biopsy to get a sample of breast tissue if a solid mass is found.

E. Removing a sample of breast cells for testing (biopsy). A biopsy to remove a sample of the suspicious breast cells helps determine whether cells are cancerous. The sample is sent to a laboratory for testing. A biopsy sample is also analyzed to determine the type of cells involved in the breast cancer, the aggressiveness (grade) of the cancer and whether the cancer cells have hormone receptors.

F. Breast magnetic resonance imaging (MRI). An MRI machine uses a magnet and radio waves to create pictures of the interior of your breast. Before a breast MRI, you receive an injection of dye. This test may be ordered after a breast biopsy confirms cancer, but before surgery to give your doctor an idea of the extent of the cancer and to see if there's any evidence of cancer in the other breast.

G. Bone Marrow Aspiration and Biopsy These two procedures are similar and often done at the same time. A bone marrow aspiration and biopsy is a diagnostic examination of the bone marrow, the red, spongy tissue inside of bone that has both fluid and solid parts. A bone marrow biopsy is the removal of a small amount of solid tissue using a hollow core needle. An aspiration removes a sample of fluid with a needle. A common site for a bone marrow biopsy and aspiration is the pelvic bone, which is located in the lower back by the hip. The skin in that area is usually numbed with medication beforehand, and other types of anesthesia (medication to block the awareness of pain) may be used. This test is used to determine if a person has a blood disorder or a blood cancer, such as anemia (a low level of red blood cells), leukemia, or multiple myeloma. It may also be used to find out if a cancer that started in another part of the body has spread to the bone marrow.

H. Positron emission tomography (PET) scan. A PET scan is a way to create pictures of organs and tissues inside the body. A small amount of a radioactive sugar or other substance is injected into a patients body and is absorbed mainly by organs and tissues that produce the most energy. Because cancer tends to use energy actively, it absorbs more of the radioactive substance. A scanner then detects this substance to produce images of the inside of the body.

IDEAL TREATMENT a. CHEMOTHERAPY Chemotherapy treatment uses medicine to weaken and destroy cancer cells in the body, including cells at the original cancer site and any cancer cells that may have spread to another part of the body. Chemotherapy, often shortened to just "chemo," is a systemic therapy, which means it affects the whole body by going through the bloodstream. There are quite a few chemotherapy medicines. In many cases, a combination of two or more medicines will be used as chemotherapy treatment for breast cancer. Chemotherapy is used to treat:

early-stage invasive breast cancer to get rid of any cancer cells that may be left behind after surgery and to reduce the risk of the cancer coming back advanced-stage breast cancer to destroy or damage the cancer cells as much as possible

b. Modified radical mastectomy Modified radical mastectomy involves the removal of both breast tissue and lymph nodes:

The surgeon removes the entire breast. Axillary lymph node dissection is performed, during which levels I and II of underarm lymph nodes are removed (B and C in illustration). No muscles are removed from beneath the breast.

Who usually gets a modified radical mastectomy? Most people with invasive breast cancer who decide to have mastectomies will receive modified radical mastectomies so that the lymph nodes can be examined. Examining the lymph nodes helps to identify whether cancer cells may have spread beyond the breast.

c. Radiation Therapy Radiation therapy also called radiotherapy is a highly targeted, highly effective way to destroy cancer cells in the breast that may stick around after surgery. Radiation can reduce the risk of breast cancer recurrence by about 70%. Despite what many people fear, radiation therapy is relatively easy to tolerate and its side effects are limited to the treated area. Radiation therapy uses a special kind of high-energy beam to damage cancer cells. (Other types of energy beams include light and x-rays.) These high-energy beams, which are invisible to the human eye, damage a cells DNA, the material that cells use to divide. Over time, the radiation damages cells that are in the path of its beam normal cells as well as cancer cells. But radiation affects cancer cells more than normal cells. Cancer cells are very busy growing and multiplying 2 activities that can be slowed or stopped by radiation damage. And because cancer cells are less organized than healthy cells, it's harder for them to repair the damage done by radiation. So cancer cells are more easily destroyed by radiation, while healthy, normal cells are better able to repair themselves and survive the treatment.

There are two different ways to deliver radiation to the tissues to be treated:

a machine called a linear accelerator that delivers radiation from outside the body pellets, or seeds, of material that give off radiation beams from inside the body

Tissues to be treated might include the breast area, lymph nodes, or another part of the body. In some cases, your doctor may recommend hyperthermia be used in combination with radiation therapy. Hyperthermia (also called thermal therapy or thermotherapy) uses an energy source such as ultrasound or microwave to heat cancer cells to high temperatures, up to 113 degrees Fahrenheit. Early research has shown that hyperthermia may make some cancer cells more sensitive to radiation. Hyperthermia is still being studied in clinical trials and isn't available everywhere. Hyperthermia and radiation are usually given within an hour of each other. Some people may fear radiation therapy. They may worry that therapeutic radiation may be dangerous like an atomic bomb or nuclear power plant. Stories about radiation side effects, some of them exaggerated, can circulate around hospital waiting rooms. It's important for you to know that there is NO connection between therapeutic radiation and the types of radiation in bombs and nuclear reactors. The radiation used in cancer treatment is highly focused, controllable, and generally safe.

d. Immunotherapy Immunotherapy, also called biological therapy, is a type of cancer treatment that uses the body's immune system to fight cancer. The therapy mainly consists of stimulating the immune system with highly purified proteins that help it do its job more effectively. To help understand the role that biological agents play in cancer treatment some understanding of how the normal immune system works is helpful.

e. Hormonal Therapy Hormonal therapy medicines are whole-body (systemic) treatment for hormonereceptor-positive breast cancers. Hormone receptors are like ears on breast cells that listen to signals from hormones. These signals "turn on" growth in cells that have receptors. Most breast cancers are hormone-receptor-positive.

About 80% of breast cancers are estrogen-receptor positive. About 65% of estrogen-receptor-positive breast cancers are also progesteronereceptor-positive. About 13% of breast cancers are estrogen-receptor-positive and progesteronereceptor-negative. About 2% of breast cancers are estrogen-receptor-negative and progesteronereceptor-positive.

If a cancer has receptors for either estrogen or progesterone, it's considered hormonereceptor-positive. There are three different types of hormonal therapy medicines:

aromatase inhibitors: o Arimidex (chemical name: anastrozole) o Aromasin (chemical name: exemestane) o Femara (chemical name: letrozole) SERMs (Selective Estrogen Receptor Modulators): o tamoxifen o Evista (chemical name: raloxifene) o Fareston (chemical name: toremifene) ERDs (Estrogen Receptor Downregulators): o Faslodex (chemical name: fulvestrant)

Hormonal therapy medicines can be used to:


lower the risk of early-stage hormone-receptor-positive breast cancer coming back lower the risk of hormone-receptor-positive breast cancer in women who are at high risk but haven't been diagnosed with breast cancer help shrink or slow the growth of advanced-stage or metastatic hormone-receptorpositive breast cancers

Hormonal therapy medicines treat hormone-receptor-positive breast cancers in two ways:


by lowering the amount of the hormone estrogen in the body by blocking the action of estrogen in the body

Because it targets estrogen, hormonal therapy is also known as anti-estrogen therapy. Estrogen has many different roles in your body, including keeping your bones strong and cholesterol low, as well as improving your sense of well-being. Before menopause, most of the estrogen in a woman's body is made by the ovaries. After menopause, the ovaries stop producing estrogen, but smaller amounts of estrogen are still made in the body; a steroid produced by the adrenal glands is made into estrogen in fat tissue. After a breast cancer is removed, the cells are tested to see if they have receptors for two hormones: estrogen and progesterone. If a breast cancer is hormone-receptor-positive, it means that it has these hormone receptors, which act like ears or antennae. When estrogen in the body attaches to the receptors, the breast cancer cells respond to signals from the estrogen that tell the cells to grow and multiply. By reducing the amount of estrogen in the body or blocking the effects of estrogen, hormonal therapy medicines can slow the growth of or shrink advanced-stage/metastatic estrogen-receptor-positive breast cancers. Lowering the amount of estrogen or blocking its effects also can reduce the risk of an early-stage, estrogen-receptor-positive breast cancer coming back after surgery. Since hormonal therapy affects the action of estrogen but not progesterone in breast cancer cells, the value of hormonal therapy is less clear if your cancer is progesteronereceptor-positive and estrogen-receptor-negative.

IX.

ACTUAL NURSING CARE PLAN

1. Impaired tissue Integrity related to effects of chemotherapy and surgery. Data Subjective: Objective Short Term: At the end of three hours of nursing interventions, the patient will be able to verbalize behaviors/lifestyle changes to promote healing and prevent complications/recurrence Long term: At the two days, the patient will be able to display progressive improvement in wound/lesion healing as evidenced by healing without redness, infection, hematoma formation and breakdown. Interventions Independent: Perform active or passive ROM at least once per shift Rationale Evaluation

Objective: Disruption of skin surface Surgical removal of the breast with axillary fat pads and some pectoralis major muscle. Destruction of skin layers or subcutaneuous tissues.

Stimulates circulation, which provides nourishment and carries away waste, thus reducing the likelihood of tis-sue breakdown.

Goal met. The patient verbalized that she needs to maintain personal hygiene in order to prevent the surgical wound from harboring pathogens.

Facilitate fluid intake Maintains fluid and to at least 2000 mL electrolyte balance, per 24 hours. which is necessary for tissue repair and normal functioning. Maintain good body hygiene. Be sure the patient has at least a sponge bath every day unless skin is too dry. Change dressings when needed using aseptic techniques Infection, through production of toxins, wastes, and so on, increases the probability of tissue damage. To prevent introduction of pathogens to the surgical wound. Prevents tissue

Collaborative:

Collaborate with dietitian regarding well-balanced diet. Assist the patient to eat as necessary. Dependent: Administer medications as ordered and record response. -Cefazolin 2grams IV ANST

breakdown due to negative nitrogen Balance.

It prevents the bacteria from biosynthesizing the framework of their cell walls. The bacteria with weakened cell walls swell and burst as a result of osmotic pressure within the cell.

Bactericidal; inhibits -Ampicillincell wall sulbactam 1.5grams mucopeptide IV ANST synthesis / inhibits beta-lactamases -Bactroban Ointment Inhibition of protein synthesis by the organism

-Co-amoxiclav 625mg PO TID

Bactericidal; only works on dividing bacteria.

2. Imbalanced Nutrition less than Body Requirements related to side effects of chemotherapy. Data Subjective: Usahay, dili ko ganahan magkaon. Tungod man siguro ni sa mga tambal na ako gi-inum, as verbalized by the patient. Objective Data: Weight 74 kg. Pale conjunctival and dry mucous membranes Loss of appetite Objectives Short Term: At the end of eight hours nursing interventions, the patient will be able to participate in meal planning so as to promote her interest to food. Long Term: At the end of two days nursing interventions, the patient will be able to display normalization of laboratory values and be free of signs of malnutrition Interventions Independent: Encourage client to eat high calorie, nutrient rich diet, with adequate fluid intake. Rationale Metabolic tissue needs are increased as well as fluids (to eliminate waste products). Supplements can play an important role in maintaining adequate caloric and protein intake. Evaluation Goal met. Patient verbalized understanding on the need to include well-cooked vegetables on her diet and to avoid eating meats.

Encourage use of supplements and frequent or smaller meals spaced throughout the day.

Create pleasant dining atmosphere; encourage client to share meals with family or friends. Adjust diet before and immediately after treatment; e.g., clear, cool liquid, light/bland foods, candied ginger, dry crackers,

Makes mealtime more enjoyable, which may enhance intake.

The effectiveness of diet adjustment is very individualized in relief of post-therapy nausea. Patient must experiment to find

toast, carbonated drinks. Give liquids 1 hour before or 1 hour after meals.

best solution or combination. Avoiding fluids during meals minimizes becoming full too quickly. Can trigger nausea/vomiting response.

Control environment factors (e.g., strong or noxious odors or noise). Avoid overly sweet, fatty, or spicy foods. Encourage use of relaxation techniques, visualization, guided imagery, moderate exercise before meals. Identify the patient who experiences anticipatory nausea/vomiting and take appropriate measures.

May prevent onset or reduce severity of nausea, decrease anorexia, and enable client to increase oral intake.

Psychogenic nausea/vomiting occurring before chemotherapy generally does not respond to antiemetic drugs. Change of treatment environment or patient routine on treatment day may be effective.

Dependent: Administer medications (5-HT3 receptor antagonists, antidopaminergics and antiemetics)

Most antiemetics act to interfere with stimulation of true vomiting center, and chemoreceptor trigger zone agents also act peripherally to inhibit reverse peristalsis. These medications are often prescribed routinely before, during, and after chemotherapy to prevent nausea and vomiting. Prevents deficit related to decreased absorption of fat soluble vitamins. -Minimizes gastric irritation, decreases nausea, and reduces risk of mucosal ulceration. -Nausea or vomiting are frequently the most disabling and psychologically stressful side effects of chemotherapy.

-Administer vitamins

-Administer antacids or proton pump inhibitor

-Administer antiemetic on a regular schedule before or during and after administration of antineoplastic

agent as appropriate. 3. Fluid volume deficit related to decreased fluid intake and presence of abnormal routes (Jackson pratt drainage on left mid-axillary line)

Data Subjective Ayha ra ko gainum kung uhawon na ko or magsakit na ako bat-ang, as verbalized by the patient. Objective Fluid intake estimated to be 2-5 glasses a day. No IVF attached dry skin/mucous membranes

Objective Short Term: At the end of the eight hours nursing interventions, the patient will be able to verbalize understanding of causative factors and purpose of individual therapeutic interventions and medications. Long Term: At the three days nursing interventions, the patient will be able to maintain fluid volume at a functional level as evidenced by individually adequate urinary output with normal specific gravity, stable vital signs, moist mucous

Interventions Independent Measure and record total intake and output every shift

Rationale Determines extent of fluid loss, need for replacement, or progress of replacement therapy. Prevents dehydration and easily replaces fluid loss with-out resorting to IVs. Frequent fluids improve hydration; variation in fluids is helpful to encourage the patient to increase intake. Older adults may not experience thirst sensation in response to fluid deprivation. Older clients may not feel thirst or dry mouth, even when

Evaluation Goal met. The patient managed to drink 840 cc of liquid because she understands the need to do so.

Assist the patient to eat and drink as necessary. Provide positive verbal support for the patients consuming fluid.

Encourage the patient to drink at least 8 ounces of fluid every hour while awake.

membranes, good skin turgor, and prompt capillary refill, resolution of edema.

dehydrated. Older clients,unprompted, may fail to drink enough fluids to stay adequately hydrated. Thus, frequent offering of fluids to the older adult is essential. Involve patient in providing a plan to regain optimal fluid balance. Collaborative Review electrolyte and renal function test result. Involving the patient in a plan improves the chances of success.

Electrolyte shifts, decreased renal function can adversely affect patients prognosis and may require additional intervention

4. Risk for Infection r/t Inadequate Immune defense due to Invasive Procedure (mastectomy) and use of Immunosuppressive Drugs (Dexamethasone) Data Subjective Data: Objectives Short Term: At the end of eight Interventions Independent: Promote good Rationale Protects client from Evaluation Goal met. The

Objective Data: Inadequate secondary defences Inadequate primary defences Invasive procedures (mastectomy) Tissue destruction and increased environmental expo-sure Immunosuppres sion

hours nursing interventions, the patient will be able to demonstrate techniques, lifestyle changes to promote safe environment

handwashing procedures by staff and visitors. Screen or limit visitors who may have infections. Emphasize personal hygiene.

sources of infection, such as visitors and staff who may have an upper respiratory infection. Limits potential sources of infection and/or secondary overgrowth. Adequate fluid intake enhances immune system and aids natural defense mechanisms. Limits fatigue, yet encourages sufficient movement to prevent stasis complications. Development of stomatitis increases risk of infection/secondary overgrowth. Reduces the risk of contamination, limits portal entry for infectious agents.

patient verbalized to stay away from crowded places while she is undergoing the treatment so that she would not catch any infectious diseases.

Long term: At the end of two to three days of nursing interventions, the patient will be able to achieve timely wound healing; be free of purulent drainage or erythema; be afebrile. Encourage fluids.

Promote adequate rest or exercise periods.

Stress the importance of good oral hygiene.

Avoid/limit invasive procedures. Adhere to aseptic techniques. Dependent:

Administer antibiotics as indicated.

Used to treat identified infection or given prophylactically in immunocompromised client

5. Disturbed body image related to changes in breast and sexuality

Data Subjective Nagbasul gyud ko na wala dayon ko nagpatambal sa una, as verbalized by the patient. Objective Left breast removed with axillary fat pads and some pectoralis major muscle.

Objectives At the end of four hours of nursing interventions, patient will verbalize at least three positive body image statements and verbalize acceptance of self in situation

Interventions independent Stay in frequent contact with the patient.

Rationale Promotes verbalization of feelings, and allows consistent intervention. Self-negating statements prolong the problem and interfere with rehabilitation potential. Maladaptive behavior supports the continuation of Disturbed Body Image.

Evaluation Goal met. The patient verbalized that she is willing to undergo the necessary treatment and that she believes that whatever may happen, its always for the best because she has already put her trust to the Lord.

Point out and limit self-negation statements.

Set limits on maladaptive behavior.

Focus on realistic goals.

Supports continued progress. Allows positive feedback for achievement, and permits the patient to see progress.

Be aware of own nonverbal communication and behavior.

Any avoidance behavior or nonverbal communication that indicates dismay would support the patients idea of her unacceptability as a damaged person. Helps the patient attend to altered body image constructively, and assists the patient to accept himor herself Helps the patient adapt to body change, and improves self-care management. Provides support for

Assist and encourage the patient to look at and use affected body part during activities of daily living. Teach the patient and significant others self-care requirements.

self-care, and assists significant others to adapt also. Collaborative: Refer the patient to available resources: Occupational therapy Facilitates adaptation and decreases isolation. Provides long-term support

IDEAL NURSING CARE PLAN Impaired Tissue Integrity related to surgery and radiation therapy Assessment Objective Data: Damaged tissue (e.g., , mucous membrane, integumentary, subcutaneous) Destroyed tissue Objectives Short Term: At the end of four hours nursing interventions, the patient will be able to verbalize understanding of condition and causative factors. Long Term: At the end of two days nursing interventions, the patient will be able to demonstrate behaviors/lifestyle changes to promote healing and prevent complications/recurrence. Intervention Keep patients skin clean, dry, and exposed to air as much as possible. Avoid constrictive clothing. Rationale To promote healing of excoriated areas and prevent infection. To reduce risk of friction and decreased blood flow. To prevent further irritation and skin breakdown. These measures reduce friction and the risk of skin breakdown on affected body parts. Evaluation

Avoid extremes of hot and cold on affected skin areas. Provide a regular change of position, a bed cradle, or pressure relieving devices, when indicated. Educate patient and family in the skin care regimen, medication

To promote compliance and maintain tissue integrity.

administration, and nutritional needs. Administer analgesics, as ordered and monitor effectiveness. Administer antiemetics, as ordered and monitor effectiveness. Analgesics reduce pain resulting from skin problems.

To promote patient comfort and adequate nutrition.

Imbalanced Nutrition: less than body requirements related to side effects of Chemotherapy Assessment Pale conjunctival and mucous membranes Weakness of muscles required for swallowing or masti-cation Sore, inflamed buccal cavity Satiety immediately after ingesting food Reported or evidence of lack of food Objectives Short Term: At the end of four hours nursing interventions, the patient will be able to verbalize understanding of causative factors when known and necessary interventions. Long Term: At the end of two days nursing interventions, the Intervention Determine patients food preferences and attempt to obtain these foods. Offer foods that appeal to olfactory, visual, and tactile senses. Offer high-protein, high-calorie supplements, such as milk shakes, custard, and ice cream. Rationale To enhance patients appetite. Evaluation

Such foods prevent body protein breakdown and provide caloric energy.

Reported inadequate food intake less than RDA (recommended daily allowance) Reported altered taste sensation Perceived inability to ingest food Misconception Loss of weight with adequate food intake Aversion to eating Abdominal cramping Poor muscle tone Abdominal pain with or without pathology Lack of interest in food Body weight 20 percent or more below ideal Capillary fragility

patient will be able to demonstrate behaviors, lifestyle changes to regain or maintain appropriate weight and Display normalization of laboratory values and be free of signs of malnutrition

Provide pleasant environment at mealtime. Avoid asking whether patient is hungry or wants to eat. Be positive in offering food. Whenever possible, sit with patient for a predetermined length of time during each meal.

To enhance patients appetite.

A positive, undemanding attitude avoids confrontation with patient. This inhibits patient from dawdling during the meal and from hiding or hoarding food

Disturbed Body Image related to changes in breast and sexuality Assessment Objective Data: Missing body part Trauma to nonfunctioning part Not touching body part Hiding or overexposing body part (intentional or unintentional) Actual change in structure and/or function Change in social involvement Change in ability to estimate spatial relationship of body to environment Not looking at body part Objectives Long term: At the end of three days, the patient will be able to: -Verbalize relief of anxiety and adaptation to actual/altered body image. -Verbalize understanding of body changes. -Recognize and incorporate body image change into self-concept in accurate manner without negating selfesteem. Intervention Independent: While assisting with self-care measures, involve patient in discussion that will provide further insights into patients coping patterns and selfesteem. Encourage patient to participate actively in performing care. Rationale Patients usual coping patterns and self-perception provide baseline data for assessing potential threat of current situation. Evaluation

This gives patient sense of independence and increase selfesteem. This helps patient ventilate doubts and resolve concerns. To increase probability that healthy adaptation will continue.

Give patient opportunities to voice feelings.

Provide positive reinforcement to patients effort to adapt.

Arrange patient to interact with others who have similar problems.

A support group allows patient to share mutual support and caring with others who can fully understand.

Risk for infection related to presence of surgical incision. Assessment Objective Data: Invasive procedures Trauma Tissue destruction and increased environmental exposure Rupture of amniotic membranes Pharmaceutical agents Malnutrition Immunosuppression Inadequate secondary defenses (e.g., decreased hemoglobin, leukopenia, suppressed inflammatory Objectives Short Term: At the end of four hours nursing interventions, the patient will be able to: - Verbalize understanding of individual causative/risk factor(s). -Identify interventions to prevent/reduce risk of infection. Long Term: At the end of two days nursing interventions, the patient will be able Intervention Have patient cough and deep-breathe every 4 hours after surgery. Teach patient about: -good hand-washing technique -factors that increases infection risk -signs and symptoms of infection Ensure adequate nutritional intake. Offer high-protein supplements, unless contraindicated. Rationale To help remove secretions and prevent pulmonary complications. These measures allows patient to participate in care and help patient modify lifestyle to maintain optimum health. Evaluation

This help stabilize weight, improve muscle tone and mass, and aids wound healing.

response) Inadequate acquired immunity Inadequate primary defenses (broken skin, traumatized tissue, decrease in ciliary action, stasis of body fluids, change in pH secretions, altered peristalsis) Chronic disease

to: - Demonstrate techniques, lifestyle changes to promote safe environment. -Achieve timely wound healing; be free of purulent drainage or erythema; be afebrile.

Help patient turn every 2 hours. Provide skin care, particularly over bony prominences. Arrange protective isolation of patient has compromised immune system. Monitor flow and number of visitors. Use sterile technique when suctioning lower airway, inserting indwelling urinary catheter, inserting IV sites catheters, and providing wound care.

To help prevent venous stasis and skin breakdown.

These measures protect patient from pathogens in environment.

To avoid spreading pathogens.

Risk for Deficient Fluid Volume related to nausea and vomiting that accompanies chemotherapy Assessment Objective data: Conditions that influence fluid needs (hypermetaboli c state) Objectives Short Term: At the end of eight hours nursing interventions, the patient will be able to: Intervention Independent: Maintain accurate record of intake and output. When copious Rationale To aid estimation of patients fluid balance. Excessive wound Evaluation

Excessive loss of fluid from normal routes (Diarrhea) Extremes of age or weight Factors that affect intake of, absorption of, or access to fluids such as immobility Loss of fluid through abnormal routes (drainage tube) Medications that cause fluid loss.

-maintain a normal vital signs. -maintain normal skin color -maintain urine output of at least 30ml/hr -electrolytes values remain within normal range.

drainage appears on dressings, weigh dressing every 8 hours and record with other output sources. Keep oral fluids at bedside within patient's reach and encourage patient to drink. Dependent: Administer parenteral fluids, as prescribed. Maintain parenteral fluids or blood transfusion at prescribed rate. Collaborative: Progress patient to appropriate diet, as prescribed.

drainage causes significant fluid imbalances.

This gives patient some control over fluid intake and supplement parenteral fluid intake. To replace fluid loss.

To prevent further fluid loss or overload.

To help achieve fluid and electrolyte balance.

X.

HEALTH TEACHINGS Coamoxiclab 62.5mg 1 capsule three times a day for seven days.(8am-2pm-8pm). To prevent the development of further infection. Etoricoxib 90mg once daily for seven days.(8am). For pain management. Pantopraxole 40mg once daily for seven days. (8am). To reduce gastric irritation brought by side effects of other medications. Pregabalin 50mg once daily for seven days.(8am). For pain management

Medication

Exercise Dont Start exercising too early consult your physician or physiotherapist Over exercise Hesitate to contact your doctor if you have a question Exercise when you have headaches, dizziness, blurred vision, new numbness, or tingling in your arms or chest Do.. Exercise within your painless range Exercise 3 times daily, if you can Contact your physician when you experienced unexplained swelling or pain Aerobic and weight gaining exercises Avoid injury to operative side; check with physician before introducing strenuous activity. EXERCISES AFTER BREAST SURGERY

Wall Hand Climbing. Stand facing the wall with feet apart

and toes as to close the wall as possible. With elbows slightly bent, place the palm of the hand on the wall at shoulder level. By flexing the fingers, work the hands up the wall until arms are fully extended. Then, reverse the process, working the hands down to the starting point. Repeat the Side Wall Climb 3 to 5 times with each arm. This helps work your shoulder joint and upper arm muscles for greater flexibility.

Rod or broom stick lifting. Grasp a rod with both hands, held about 2 feet apart. Keeping the arms straight, raise the rod over the head. Bend the elbows to lower the rod behind the head, then return to starting position. Repeat this exercise 5 to 7 times. Don't worry if you can't lift the rod or broomstick all the way up - just do as well as you can. Gradually increase your stretching, so you may become more flexible. Try not to move your shoulder blades during this exercise just concentrate on your shoulder motion.

Chest Stretch. Raise your surgery-side arm up, until it is perpendicular to your body. Slowly and carefully lower your arm down and to the side. Feel a gentle stretch in your chest wall muscles. Stop lowering your arm if the stretch is painful

- do not do this exercise to the point of pain. Hold this position for about 30 seconds.

Towel Stretch. Stand up straight with the towel draped across your right shoulder. Hold the front of the towel in your right hand, and the back of the towel in your left hand, behind your back. You're now in your starting position. Use your right hand to gently pull down on the towel. This will stretch your left arm and cause your left shoulder to rotate. When you feel your left arm stretching, hold that position for about 30 seconds and then relax. Do the towel stretch 3 times, then switch arms. Stretch your other arm 3 times. Do the towel stretch twice a day. If you don't see improvement right away, don't worry - shoulder rotation can take several weeks to restore. Just do your best and keep to your regular exercise schedule.

Treatment Chemotherapy Chemotherapy is treatment of cancer with anticancer drugs The main purpose of chemotherapy is to kill cancer cells. It usually is used to treat patients with cancer that has spread from the place in the body where it started (metastasized). Chemotherapy destroys cancer cells anywhere in the body. It even kills cells that have broken off from the main tumor and traveled through the blood or lymph systems to other parts of the body. Chemotherapy can cure some types of cancer. In some cases, it is used to slow the growth of cancer cells or to keep the cancer from spreading to other parts of the body. When a cancer has been removed by surgery, chemotherapy may be used to keep the cancer from coming back (adjuvant therapy). Chemotherapy also can ease the symptoms of cancer, helping some patients have a

better quality of life. Before starting chemotherapy please let your doctor or nurse know beforehand. Please discuss any concerns with your doctor or nurse. Appetite and Taste Changes During chemotherapy, you may experience taste and appetite changes and a heightened sensitivity to odors. Don't worry if you don't have an appetite the first few days or a week following chemotherapy; it is not unusual. As you feel better, your appetite will improve. Reflux when food backs up into your esophagus burping, or a burning sensation may worsen nausea. Please report these symptoms to your physician or nurse so that they can be treated. Radiation therapy:

The use of high-energy rays to damage cancer cells, stopping them from growing and dividing. Like surgery, radiation therapy is a local treatment that affects cancer cells only in the treated area. Radiation can come from a machine (external radiation) or from a small container of radioactive material implanted directly into or near a tumor (internal radiation). External radiation therapy is usually given on an outpatient basis in a hospital or clinic. Patients are not radioactive during or after external radiation therapy. For internal radiation therapy, the patient stays in the hospital for a few days. The implant may be temporary or permanent. After an implant is removed, there is no radioactivity in the body. The amount of radiation in a permanent implant goes down to a safe level before the patient leaves the hospital. Side effects of radiation therapy depend on the treatment dose and the part of the body treated. The most common side effects of radiation are: fatigue, skin reactions (such as a rash or redness) in the treated area, loss of appetite. inflammation of tissues and organs in and around the body

site that is radiated. decrease in the number of white blood cells. Although the side effects of radiation therapy can be unpleasant, they can usually be treated or controlled. Furthermore, in most cases, they are not permanent. Report signs of infection(redness, swelling, warmth, or pus at the site of injury or surgical wound, cough or shortness of breath,mucus or pus in the saliva,nasal drainage,fever of 100.5 degrees F or higher,sore throat,burning sensation while urinating,chills or shakes) Take a warm shower to relieve referred muscle pain. Outpatient Diet OPD follow-up July 5, 2012, 9 am with Dr. Melicor Eat 5 or more serving of fruits and vegetables each day Alcoholic beverages must be eliminated Limit the intake of highly saturated foods such as beef, lamb, organ meats, cheeses, cream, butter, ice cream Decrease intake of food containing trans fatty acids, such as commercially prepared baked goods, crackers and margarine Increase your intake of poultry, fish and vegetarian proteins (legumes and lentils). Increasing your intake of fish to 3 times per week will increase omega-3-polyunsaturated fat intake. Research has suggested that these fatty acids may inhibit the growth of breast tumors.

XI.

DOCTORS ORDER Doctors order Pls. admit to room of choice Secure consent for admission and care To provide medical management and further monitoring. Signed consent ensures that the patient is properly informed regarding the process, risks and possible complications of the procedures and is not forced to undergo the said procedures. Referred to Dr. Melicor for Modified Radical Mastectomy This will prevent poor nutrition status because cancer patient in good nutrition status is less susceptible to infection and probably tolerates cancer therapy better. Ensure cardiopulmonary clearance before procedure. Attach laboratory results to determine for any abnormalities before the procedure. For co-management To determine Hgt level before and after the procedure To prepare the Operating room for the surgery Measurement of the patients fluid intake and output will identify if she is at risk for becoming dehydrated or over-hydrated.

6/27/2012 (1:25 pm)

For MRM (L) care off Dr. Allan Melicor DAT

Labs: please attach lab result from OPD; Attach CP clearance done at OPD

Dr. Ledress for anesthesia Hgt pre and post MRM Inform OR staff and Dr. Melicor of this admission for OR schedule MIO shift

V/s q4 Refer accordingly 1:40 pm Please give Vit. K 1 tab now and then TID For blood typing To secure 1 unit of FWB of pts blood type NPO after light breakfast

To determine baseline data and to monitor any unusualities. For proper referral Vit. K helps the liver produce the factors necessary for blood clotting. To determine the blood type of the patient For possible OR use NPO is ordered prior to the upcoming medical procedure/surgery or test to prevent aspiration while the patient is anesthesized or unconscious. For operation. It is a procedure in which the entire breast is removed, including the skin, areola, nipple, and most axillary lymph nodes It is a proton-pump inhibitor that act as specific secretory surface receptors to prevent the final step of acid production and thereby decrease the level of acid in the stomach. Prophylaxis for pulmonary aspiration in surgical patients. NPO is ordered prior to the upcoming medical procedure/surgery or test to prevent aspiration while the patient is anesthesized or unconscious This is a narcotic agonist

Schedule for MRM (L) on 28 June 2012

Pls. administer pantoprazole 40 mg 2 tabs at 6am tomorrow then strict NPO there after

Prescribe Oxynorm

10mg+Precedex+PCA tubing

Cefazolin 2 grams IV ANST on call to OR

which acts at specific opioid receptor site in the CNS to produce analgesia, sedation, and a sense of well-being. And this is given to the patient to relief of severe acute or chronic pain. A first generation cephalosporin which prevents the bacteria from biosynthesizing the framework of their cell walls. The bacterial with weakened cell walls swell and burst as a result of the osmotic pressure within the cell. It is ordered for the patient as a prophylaxis to prevent infection while undergoing surgery. Drug to drug interaction of Vit.K with antibiotics (cephalosporin) and analgesics will increase the risk for bleeding. IV administration is performed to replace fluids, administer medications, and provide water and electrolyte. This is being ordered because some bacteria developed an enzyme called penicillinase, which effectively inactivates many of the penicillin, but this combination allows sulbactam to inhibit many bacterial penicillinase enzymes, broadening the spectrum

Vit. K 1 tab BID

Start IV with D5LR iL @ 30 gtt/smin

Change cefazolin to ampicillinsulbactam (ampimax) 1.5 gram IV ANST on call to OR

Vit K. 1 amp IV now then q6

of ampicillin (bactericidal) Vit. K helps the liver produce the factors necessary for blood clotting To let the patient rest comfortably This will prevent poor nutrition status because cancer patient in good nutrition status is less susceptible to infection and probably tolerates cancer therapy better To have baseline data and to determine whether symptoms of shock are present. To monitor and determine the severity of pain prior to administration of analgesic medication For regulation. IV administration is performed to replace fluids, administer medications, and provide water and electrolyte Parecoxib is being given to patient early post operative because it will inhibit COX-2 enzymes which is are involve in the synthesis in the prostaglandin and thereby reduce pain and inflammation. But Etoricoxib is for chronic musculoskeletal pain and also acute pain by inhibiting COX-2 enzyme this reduce

6/28/2012

Post-op Orders o To pts room once stable at RR o DAT when fully awake

o V/S to include

o Pain score q15minutes until stable then q4

o Regulate IVF @ 30gtts/min then ff: NSS iL to run in 12 hours D5LR iL to run in 12 hours

o Meds Parecoxib 40mg IV q8 RTC 6 doses only then shift to Etoricoxib 90 mg (arcoxia) 1 tab to start 6 hours after the last dose of Parecoxib OD PO atleast for 5 days only

prostaglandins from arachidonic acid. Continue Pantoprazole 40 mg 1 tab OD PO times 6 days A proton pump inhibitor used prophylactically before and after surgery to reduce gastric acid production triggered by analgesics, antibiotics and stress. Before surgery, reducing gastric acid secretion also decreases the risk for aspiration while being sedated with a general anesthesia. This is a narcotic agonist act at specific opioid receptor site in the CNS to produce analgesia, sedation, and a sense of well-being. And this is given to the patient to relief of severe acute or chronic pain and Oxynorm is also same in only matters in their brand. This is a gastrointestinal stimulants which will stimulate parasympathetic activity within the GI tract, this drugs act to increase GI secretions and mortility on a general level throughout the drugs to prevent nausea and vomiting. Pregabalin is an analog of the neurotransmitter GABA. It binds potently to the alpha2-delta subunit resulting in

Oxycontin 10 mg 1 tab q8 given q 10:00 pm 6 am and 2 pm x 4 days only May give Oxynorm 5mg/capsule Give 1 cap as rescue dose for more breakthrough pain May be given even at an hourly interval per pts demand until pain score are at acceptable 3/10 or below

6/28/12 Post op. orders meds. May give plasil 10 mg (metoclopramide) 1 amp IV q6 if patient has NV

Start Pregabalin 50 mg (lyrica) 1 cap q8pm OD PO to be continued at home for at least 15 days

O2 inhalation 2L/hr until patient is fully awake

Refer accordingly 6/28/2012 (7 pm) DAT

modulation of Ca channels and reduction in the release of several neurotransmitters, including glutamate, norepinephrine, serotonin, dopamine, and substance P. Oxygen therapy is given to prevent cellular hypoxia caused by decreased functional residual capacity within the lungs due to the general anaesthesia given prior to surgery (thoracic surgery). For proper referral This will prevent poor nutrition status because cancer patient in good nutrition status is less susceptible to infection and probably tolerates cancer therapy better Bladder distention not noted. Patient can manage to urinate in the bedpan or comfort room. To have baseline data and to determine if there are abnormalities. This will prevent poor nutrition status because cancer patient in good nutrition status is less susceptible to infection and probably tolerates cancer therapy better Blood transfusions are done to replace blood lost during surgery or due to a serious injury.

Remove FC

Kept Hgb, Hct in Am reg

6/30/2012 Ambulatory, afebrile, tolerated solid food, Repeat Hgb 9.2, Hct 29.6

DAT

Transfuse available FWB in a settled RBC x 4 hours

Decrease IVF on KVO while on BT

Bill for discharge in AM Repeat CBC in AM

IVF to ff. D5LR iL x 30 gtts/min

A transfusion also may be done if your body can't make blood properly because of an illness. It is important to decrease regulation while doing BT to prevent increase of blood volume. In am because that is the time that the billing office is open. Complete blood count is ordered to determine the total number of WBC, RBC, platelet count, hemoglobin and hematocrit. For regulation. IV administration is performed to replace fluids, administer medications, and provide water and electrolyte A loop diuretic drug block the chloride pump in the ascending loop of henle, where normally 30% of all filtered sodium is reabsorbed. This action decreases the reabsorption of sodium and chloride. It is ordered for the patient to treat her bipedal edema. Termination of IVF may be done if the fluids and electrolytes are already replaced or is within normal Penicillin bactericidal to

7/01/2012 (2:00pm) Bipedal edema grade 1 pitting Furosemide 4 mg 1 tab single dose now

Decrease IVF to 10 gtts/min to consume then D/C

7/01/2012 (2:30 pm)

Coamoxiclav 62.5 mg i cap TID PO

Pain 0/10, tolerated ROM solid foods; ambulating, (-) BM, (+) BPE grade 1,Status post BT as yesterday, clear breath sounds, normal VS (-) fever, JP1-95 cc/day, JP265 cc/day, BPE 2 fluid retention 2 BT, anemia considered

D/C IVF

MGH in Am Home meds: o Coamoxiclav 625 mg TID x 7 days 8-2-8 o Etoricoxib 90 mg OD x 7 days 8

prevent skin and soft tissue infections . Termination of IVF may be done if the fluids and electrolytes are already replaced or is within normal patient is advised to be at home while recovering from the operation. Penicillin bactericidal to prevent skin and soft tissue infections Etoricoxib is for chronic musculoskeletal pain and also acute pain by inhibiting COX-2 enzyme this reduce prostaglandins from arachidonic acid

o Pantopraxole 40 mg OD x 7 dsys 8

o Pregabalin 50 mg OD x 7 days 8 OPD follow-up July 5, 2012, 9 am with Dr. Melicor For change with dressing 9 am OPD

This is a prohylaxis because the patient is stress so there is a build-up of acid

For follow-up check up To abate blood flow, provide relief from pain, enhance the healing process, protect the wound from infection, remove foreign particles, and to absorb any fluids discharged from the wound. To promote proper circulation and good muscle tone.

ROM exercise

7/02/2012 Dulcolax 2 tabs tonight if unable to defecate today Hold MGH orders Dulcolax is a laxative medication to enable the patient to defecate Because there is more monitoring that is needed to be done. Soothes and protects the wound and allows free passage of exudate Bactigras is soothing and low-adherent and allows the wound to drain freely into an absorbent secondary dressing. Is used to treat certain skin infections. It is an antibiotic that works by stopping the growth of certain bacteria This is being prepared to save time and effort in the procedure of removing staple

7/3/12 (10:00 am) Prepare Bactigras # 2

Mupirozin Cream #1

Staple wire remover #1

(11:30 am) -dry round graft-blister top, to fleshy red below; (-) discharges MGH as previously ordered Change with dressing done

Provide measuring cap to folks

patient is advised to be at home while recovering from the operation. To abate blood flow, provide relief from pain, enhance the healing process, protect the wound from infection, remove foreign particles, and to absorb any fluids discharged from the wound For measuring the amount of discharges from the 2 Jackson pratt drainage.

XII.

PROGNOSIS

Way back 2009, the patient had consultation at Bukidnon Provincial Hospital and was diagnosed with Benign Breast Tumor, Jane Doe was 57 year old that time. With so much doubt, the patient sought for 2nd opinion at the same institution, and she was again diagnosed with Benign Breast tumor. Because shes not satisfied with the result she sought 3rd opinion at Bethel Baptist Hospital last December 2012 and she was then diagnosed with cancerous breast tumor at the age of 60 year old. Most cases of breast cancer occur in women older than age 60.According to the American Cancer society ,about 1 in 8 cases invasive breast cancer occur in women age 55 and older. For stage 2,3 and 4 breast cancer, women between 40 and 49 years of age show the highest survival rate s, while women above 70 tend to show the poorest survival rate for stage 3 and 4 breast cancer .And after being diagnose with breast cancer ,the patient is risk of developing it again, either in the same breast or in the other breast. Being a woman is the most significant risk factor for breast cancer although men can get breast cancer too ,the ratio is 99:1,womens breast cell is constantly changing and growing, mainly due to the activity of the female hormones estrogen and progesterone. This activity puts them at much greater risk for breast cancer. And also the patient has a first-degree relatives (brother) who had been diagnosed with thyroid cancer and also the patient has a myoma and thats make her double the risk of developing a breast cancer. Patient Jane Doe got pregnant of her 3rd child at the age of 40, according to studies women who got pregnant after 30 year old may have slightly increased breast cancer risk. And also the patient is not breastfeeding and studies shows that breastfeeding reduces a womans total number of menstrual cycle, and thereby estrogen exposure which may account for its possible protective effects .Some studies suggest that the longer a woman breastfeed, the lower the risk ,and that breastfeed may be most protective for women with a family history of breast cancer. Patient Jane Doe usual diet is red meat she does not eat vegetables and according to studies red meat and animal fats may contain hormones, growth factors and pesticides. Some researchers believes that eating too much cholesterol and other fats are risk factors for cancer, and studies show that eating a lot red and/or processed meat is associated with a higher risk of breast cancer. Patient Jane Does family is very supportive they provide all her needs specially the medication and go with her and guide her in her scheduled treatment. Study show that patients who receive adequate support from their family members have less anxiety and depression, better adaptation and are more efficient in coping with their illness. It

seems that family members can promote patient autonomy, help them to cope with stressful events and enhance mental well-being in patients with breast cancer.

EVALUATION: According to the patients final pathologic report last july 10,2012 it states that the Nottingham Histologic Grade is grade 2,tumour size is 3.5 and lymph nodes is 3. Formula: NPI=(0.2x tumour diameter in cm)+lymph node stage+ tumuor grade = (0.2x3.5cm) + 3 + 2 =5.7 Parameters are: A score of less than 4-this suggests a good outcome with a high chance of a cure A score of 4.01-5.4 this suggest an intermediate level with a moderate chance of cure A score of more than 5.4-this suggest a lower chance of cure

And according to research breast cancer are more likely to come back within 2 years and it is more likely to be cured if the cancer has not come back within 5 years. But unfortunately, breast cancer can come back 10 or 20 year after the patients were first diagnosed. But this is not common and the more time passes since the diagnosis, the less likely the cancer will come back.

XIII.

RESEARCH UPDATE

Green vegetables proven to protect against breast cancer October 04,2012:(NaturalNews) Eating more cruciferous vegetables has been shown once again to play an important role in the mitigation of cancer, this time in helping women with breast cancer to live longer. A Chinese study recently presented at the 103rd annual meeting of the American Association for Cancer Research (AACR) revealed that the more cruciferous vegetables women with breast cancer eat, the more likely they are not only to survive their condition, but also to add more years onto their lives.Based on data collected for the Shanghai Breast Cancer Survival Study, a comprehensive, large-scale study of breast cancer survivors in China, it appears as though consumption patterns of cruciferous vegetables, or vegetables from the cabbage family, are directly proportional to survival rates. The breast cancer-specific mortality rate among women who consumed the most cruciferous vegetables, for instance, was as much as 62 percent less than among those who consumed the least or no cruciferous vegetables.At the same time, the overall mortality rate among women who consumed cruciferous vegetables on a regular basis was found to be anywhere from 27 to 62 percent less than among women who consumed little or no cruciferous vegetables. And risk of breast cancer recurrence among cruciferous-eating women was as much as 35 percent lower than among non-eating women. "Commonly consumed cruciferous vegetables in China include turnips, Chinese cabbage (bok choy) and greens, while broccoli and brussels sprouts are the more commonly consumed cruciferous vegetables in the United States and other Western countries," said Dr. Sara Nechuta, a postdoctoral research fellow at Vanderbilt University and author of the study."Second, the amount of intake among Chinese women is much higher than that of U.S. women. The level of bioactive compounds such as isothiocyanates and indoles, proposed to play a role in the anti-cancer effects of cruciferous vegetables, depend on both the amount and type of cruciferous vegetables consumed." Cruciferous vegetables contain a variety of anti-cancer nutrients that have been shown in previous studies to both fight cancer cells and prevent them from forming. Sulforaphane, an organosulfur compound found in broccoli, cauliflower, and cabbage, for instance, is a powerful anti-cancer nutrient that also performs a number of beneficial functions in the body (http://www.naturalnews.com).Isothiocyanates are another anticancer nutrient in cruciferous vegetables that activate cancer-fighting genes. Both systemically and genetically, cruciferous vegetables help fight and prevent cancer, and are a great way by which to protect yourself against this pandemic condition.

Reference: http://www.naturalnews.com/035623_cruciferous_vegetables_breast_cance r_prevention.html#ixzz297BRCUdK

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