NURSING CARE of CA MAMMAE

1. ASSESSMENT A. IDENTITY CLIENT IDENTITY Name Sex Age Address Education Occupation Marital status Religion Tribe / Nation RS Entry Date Medical Diagnosis RM Number

: : : : : : : : : : : :

Mrs. D.P Female. 21 years. Jl. Penghulu Senior High School Private. Married Islam. Banjar / Indonesia. July 7, 2010 Ca mammae (Malignant Neoplasma of Breast) 879987

RESPONSIBLE INSURER IDENTITY Name : Mr. D.R Sex : Male Age : 20 years Occupation : Private Address : Jl. Penghulu Relationship with client : Husband B. HEALTH HISTORY 1. The Main complaint At the time of assessment on 8 July 2010, at 9:00 pm, client said that her left breast feel a little pain and worry with the disease and the actions will be done. 2. The present illness history approximately one year ago, clients felt there was little tumor like marble the left side of her breast but did not feel pain, after some time in the last weeks before she was admitted to hospital, client done self breast care on the breasts and palpated there is the tumor on the left side of her breast like adults thumb and feel painful, because worried with the client condition , client and her husband went to check-up to the doctor. From the assessment found that medical diagnosis is ca mammae suffered by clients that caused by hormonal factors, from the emergency room clients were referred on 7 July 2010 to Nusa Indah to do long stay department and to do intensive care. 3. The Past Illness History Client says has never suffered a serious illness like she suffered now, just a cough and typhoid.

4. The Family Disease History Clients say that none of her family members who experience such ca mammae diseases like suffered by clients now and none of client families have a infectious disease history but the client's mother has a history of hypertension. C. PHYSICAL EXAMINATION 1. General condition At the time of assessment dated 8 July 2010, client awareness is compos mentis (fully conscious, able to answer all questions with the co-operative) with GCS: 4-5 - 6 (E4: eyes open spontaneously, V5: good orientation and M6: follow orders) with vital signs : Blood pressure: 120/80 mmHg, Pulse: 84 beats / minute, Respiratory Rate: 28 times / minute and Temperature: 36,90 C, and anthropometric data are :Body Weight: 43 Kgs, Body height: 153 Cms and upper arm circumference : 23 Cms Ideal Body Weight = (153-100) - 10 % (153-100) Kgs = 53 5, 3 Kgs = 47, 7 Kgs 2. Skin skin is Brown color, skin condition is clean, there are no red spots, there is not inflammation or lesion, skin texture is moist, skin turgor is good (back before 2 seconds) and no other disorder form such as cyanosis or ikterik. 3. Head and Neck hair distribution is prevalent, there is no bump on the head, there is no lesion, clients hair is black and straight, the head cleanliness is clean and there is no headache or head trauma, no enlargement of the thyroid gland in the neck, no enlargement of lymph nodes, there is no pain when movement, there is no limitation of motion in the neck. 4. Eyes and eyesight eye structure is Symmetrical, the eyes look clean, no secretions in the eyes, conjunctiva is not anemic, sclera is no ikterik , no abnormalities in the eyeball and movable to all direction, client is not using visual aids such as glasses and contact lens and vision function well marked client can read the nurses shingle. 5. Nose and smell nose structure is Symmetrical, the nose look clean, it appears there is no dirt or obstruction on the nose and there was no bleeding, no inflammation or pain in the nostrils, there was no use of the nostrils during breathing, olfactory function is good was marked with a client can distinguish smells between cajuput oil and orange. 6. Ear and hearing both ears structure is Symmetrical, the client ears look clean, there is no secret that comes out, no pain, inflammation or bleeding, the client does not using hearing aids and hearing function is well marked by the client can answer all nurses questions well.

7. Mouth and teeth Oral hygiene is clean, there is no inflammation of the mouth, client's dental hygiene is clean, there is no inflammation of the gums and no chewing and swallowing disorders. 8. Chest, breathing and circulation Chest form is Normal with a ratio between the anterior posterior diameter and transverse diameter is 1:2, the movement left and right chest looks symmetrical, clients respiratory is eupnea (normal breathing rhythm and speed), when in percussion is resonant sound and there is no buildup of fluid in the lungs, when auscultation is vesicular breath sounds (low and soft), there is extra heart sound (single-S1 and S2), a normal CRT ( Capillary Refill Time ) back less than two seconds, when inspection, breast is normal and symmetrical and can be described is medium form, breast skin color is olive, there is no lesion and no edema in the breasts, there are no retraction in the breasts and there is no swelling of the nipples, when palpated with self care techniques of the breasts aware there is a tumor like adults finger at the left side breast, the client says little pain with a pain scale is one ( middle pain) when held or sometimes just appears like an ant bite but rarely. 9. Abdomen Abdominal structure is symmetrical, there is no lesion and there is no lump, no ascites. When auscultation, bowel sounds is 10 times / minute. When percussion is tympani sound and when palpated there is no mass in the abdomen, there was no enlargement of liver and lymph. 10.Genital and Reproduction client is Female, the client does not use the catheter, there is no pain during bowel and bladder, the client is the first child of three brothers, married approximately 1 years ago, client does not has children yet, there is no using contraception drugs either pills or injections. Clients menstrual cycle is irregular, slow, and when menstruation is eight days, clients say sometimes until the second moon periods the menstruation begin comes and are not checked. 11. Extremities on top and bottom The structure of right and left extremities are symmetrical, infusion is not installed on the extremities, no pain, inflammation or bleeding on extremities, no limitation of motion, muscle strength scale 5555 5555 (normal movement, full of challenging gravity) 5555 5555

D. PHYSICAL, PSYCHOLOGICAL, SOCIAL AND SPIRITUAL NEEDS 1. Activity and rest Home : Client is a housewife and employer at PT. JAMSOSTEK (Persero) of branch office South Kalimantan, client sleep in the night around 7-8 hours and sleep in the afternoon around 1 hour. In the Hospital : During in hospital client sleep in the night around 7 to 8 hours and in the afternoon two hours, clients can conduct their own activities without help from others with the activity scale is 0 (independent) 2. Personal Hygiene Home : client takes a bath two times a day, brush her teeth four times a day, washed her hair three times a week and cut the nails when the length In the Hospital : client takes bath 2 times a day, brush her teeth two times a day, washed her hair if necessary, and no cutting nails 3. Nutrition Home : client eats three times a day, ordinary rice foods + side dish + vegetables, clients have food restrictions such as shrimp, client has a good appetite, client drinks around 7 cups per day and there is no difficulty in swallowing In the Hospital : clients eat three times a day with diet NB (normal rice), and the client drinks five glasses a day and clients appetite is not disturbed, normal rice with high calories and high proteins. 4. Elimination Home : the frequency of defecate is normal one time a day, the time is in the morning, consistent is soft, yellow and do not use laxatives, urinate 3-4 times per day, no pain during defecate and urinate. In the Hospital : frequency of defecate is normal one time a day, the time is in the morning with a consistent is soft, yellow and not using laxatives, urinate around 5 times a day, no pain during defecate and urinate. 5. Sexual A client was married and has not children, no complaints in sexual relations. 6. Psychosocial Clients be able to communicate well and there is no mental disorder, the client looked anxiety when she discovered her illness and when in hospital, Client can establish good relationships with family, doctors, nurses who cared for her, client looking anxious, the client can easily adapt to the environment, anxiety scale is 3 (level of concern is increases) 7. Spiritual Clients Moslems, on the hospital client sometimes remembrance and always pray for a speedy recovery illness.

E. SUPPORTING DATA Examination Hematological Hemoglobin leukocytes Erythrocytes Hematocrite Platelet RDW-CV MCV, MCH, MCHC MCV MCH MCHC differential count Basofil % Eosinophils % Neutrophils % Lymphocytes % Monocytes % Basofil # Eosinophils # Neutrophils # Lymphocytes # Monocytes # Prothrombin time PT results INR Control normal PT APTT APTT result Control normal APTT

Result 11,8 * 9,3 3,81 * 32 * 209 12,7 83,2 31,0 37,2 0,2 3,6 * 67,7 21,9 * 6,6 0,02 0,33 * 6,26 2,03 0,61 13,4 0,96 13,80 32,8 32,20

Reference value 12,0 16,0 4,0 10,5 3,90 - 5,50 35 45 150 450 11,5 - 14,7 80,0 97,0 27,0 32,0 32,0 38,0 0,0 1,0 1,0 3,0 50,0 70,0 25,0 40,0 3,0 9,0 <0,1 <0,3 2,50 7,00 1,25 4,00 0,30 1,00 11,5 15,5 26,O 34,0 -

Unit g/dl Thousand/ul Million/ul Vol % Thousand/ul % Fl Pg % % % % % % Thousand/ul Thousand/ul Thousand/ul Thousand/ul Thousand/ul second second second second

F. DATA FOCUS  Subjective Data y Client says her left breast feel a little pain y Client says feel worry with the disease and the actions will be done y Client says little pain with a pain scale is one (little pain) when held or sometimes just appears like an ant bite but rarely  Objective data - Inspection y client looking anxious y Clients seem agitated y Anxiety scale 3 (level of concern is increases) y Respiratory Rate: 28 times / minute & Temperature: 36.9 o C

- Palpation y there is a tumor like adults finger at the left side breast y pulse: 84 times/ minute - Percussion ------- Auscultation y Blood Pressure: 120/80 mmHg

II. DATA ANALYSIS AND DATA SYNTHESIS No Data Problem 1 Subjective Data: Acute pain y Client says her left breast feel a little pain y Client says little pain with a pain scale is one ( middle pain) when held or sometimes just appears like an ant bite but rarely Objective Data: y Pain characteristic: P: little pain at the breast when held or sometimes Q: appears like an ant bite R: the left side breast S: a pain scale is one (little pain) T: rarely y Vital Signs : - Blood Pressure:120/80 mmHg - Respiratory Rate: 28 times/minute - Pulse: 84 times/minute - Temperature: 36,9 o C Subjective Data: anxiety - Client says feel worry with the disease and the actions will be done Objective Data: - Client looking anxious - Clients seem agitated - Anxiety scale 3 (level of concern is increases) Subjective Data: Acute pain - client says pain in the left side of the breast due to the surgical procedure with pain scale is 2 ( middle pain ), the time is uncertain, such as pulse Objective Data: - Pain Characteristic : P: Pain due to surgical procedures Q: appeared such as pulse R: the left side of the breast S: Pain scale 2 ( middle pain ) T: time is uncertain - Client looks winced in pain when the pain appeared - client was lying in bed - visible presence of breast masses removed from clients breast like chicken eggs such as boiled chicken meat - Vital Signs : y Blood Pressure:120/70 mmHg

Etiology Injury agents (physical)seconda ry with tumor mass on breast

Situational crises (cancer)

Post op excision removal tumor

y Pulse: 90 times/ minute y Respiratory Rate: 22 times/ minute y Temperature; 36,5 o C Risk factors: - look Hipapix closes the stitches clean and white color - Looks the stitches on the left breast wrapped with 6 cm long of the hipapix - Look closed wound

Risk for Invasive infection Procedure

 Nursing diagnosis priority on July 8 2010 (Pre Op) 1. Acute pain related to Injury agents (physical) secondary with tumor mass on breast 2. Anxiety related to Situational crises (cancer)  Nursing diagnosis priority on July 9 2010 (Post Op) 1. Acute pain related to Post op excision removal tumor 2. Risk for infection related to invasive procedure

III. INTERVENTION Planning No 11 1 Day/Date Thursday 8 July 2010 Nursing Diagnosis Outcomes Acute pain related to Injury agents (physical) secondary with tumor mass on breast Subjective Data: y Client says her left breast feel a little pain within 6 hours, pain problem can be solved with the evaluation criteria: Intervention y Determine pain history, location, duration and intensity y Evaluate the therapy: surgery, radiation, chemotherapy, biotherapy y Give distraction technique such as listening the music or watching the television y Advice technique handle of stress ( relaxation technique, visualization, guidance ) and give therapeutic touching y Evaluate pain, give medication if needed Rational y Give information that the client needed to do nursing care y To know that therapy is needed or unneeded or can grow side effect y To increase convenience by calls away the attention client of pain

y Client does not say her left breast feel a little pain

y Client says little pain y Client does not with a pain scale is say pain with pain scale is 0 ( one ( little pain) there is no pain ) when held or sometimes just appears like an ant bite but rarely Objective Data: y Pain characteristic: P : little pain at the breast when held or sometimes Q : appears like an ant bite R : the left side breast S : a pain scale is one ( middle y Vital Signs is pain) normal: T: rarely - Blood Pressure:120/80 y Vital Signs : mmHg - Blood - Respiratory Rate: Pressure:120/80 12 - 24 mmHg times/minute - Respiratory Rate: 28 times/minute - Pulse: 80 - 100 times/minute - Pulse: 84 - Temperature: 36 times/minute - 37 o C - Temperature: 36,9 o C

y Increase self control of side effect with decreasing of stress and anxiety

y Discuss about pain handling

y To know pain handle effectiveness, degree of pain until how client can handle it and to know client requirement of analgesic y That therapy is given correctly

Thursday 8 July 2010

Anxiety related to Situational crises (cancer) Subjective Data: - Client says feel worry with the disease and the actions will be done Objective Data: Client looking anxious Clients seem agitated - Anxiety scale 3 (level of concern is increases)

within two days, Anxiety problem can be solved with the evaluation criteria: - Client does not say feel worry with the disease and the actions will be done - Client does not looking anxious - Clients does not seem agitated - Anxiety scale 0 (there is no anxiety)

with the doctor y Give analgesic y To handle pain according indications y Previous y The data clients according experience clients before experience according his before will disease that give she suffered foundation for counseling and avoid duplication y Give y Giving information information about can help client prognosis with to understand accurately her disease process y Give y Can decrease opportunity to client anxiety the client to express her anger, fear y Explain y Help client to medical understand procedure, client needed purpose and on medicine side effect. and side effect Help the client on the procedure y Evaluate the y To know pain, give the affectivity on medicine if handling pain, needed degree of pain until how long the client can face the pain and to know client needs antibiotic y Discuss how y To effective

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Friday/ 9 July 2010

Acute pain related to Post op excision removal tumor Subjective Data: - client says pain in the left side of the breast due to the surgical procedure with pain scale is 2 ( middle pain ), the time is uncertain, such as pulse Objective Data: - Pain Characteristic : P: Pain due to surgical procedures Q: appeared such as pulse R: the left side of the breast S: Pain scale 2 ( middle pain ) T: time is uncertain - Client looks winced in pain when the pain appeared - client was lying in bed - visible presence of breast masses removed from clients breast like chicken eggs such as boiled chicken meat - Vital Signs : y Blood Pressure:120/70

to handle the therapy pain with the doctor and also client y Give analgesic y Minimalism according and also indication handle the such as morfin pain Within three days, y Determine y Give pain problem can pain history, information be solved with the location, that the client evaluation criteria: duration and needed to do - Client does not intensity nursing care say pain in the y Evaluate the y To know that left side of the therapy: therapy is breast due to the surgery, needed or surgical radiation, unneeded or procedure with chemotherapy, can grow side pain scale is 0 ( biotherapy effect no pain ) y Give y To increase - Client in the nice distraction convenience position technique such by calls away - There is not the as listening the the attention mass in the music or client of pain clients breast watching the again television - Vital Signs is y Advice y Increase self normal: technique control of side y Blood handle of effect with Pressure:120/80 stress ( decreasing of mmHg relaxation stress and y Respiratory technique, anxiety Rate: 12 - 24 visualization, times/minute guidance ) and y Pulse: 80 - 100 give times/minute therapeutic y Temperature: 36 touching o - 37 C y Evaluate pain, y To know pain give handle medication if effectiveness, needed degree of pain until how client can handle it and to know client requirement of
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mmHg y Pulse: 90 times/ minute y Respiratory Rate: 22 times/ minute y Temperature: 36,5 o C 4 Friday/ 9 July 2010 Risk for infection related to invasive procedure Risk factors: - look Hipapix closes the stitches clean and white color - Looks the stitches on the left breast wrapped with 6 cm long of the hipapix - Look closed wound

within two days, Risk for infection problem can be solved with the evaluation criteria: - Client is able to identify and participate in prevention of y Monitor the infection temperature - shows no signs of infection and y Assess all wound healing system to lasted normally identify the infection y Avoid/ determine invasive procedure and keep aseptic procedure y Collaborate: - Monitor RBC, WBC, granulocyte, platelet - Give antibiotic if indicate

y Discuss about pain handling with the doctor y Give analgesic according indications y Wash hand before done the action and also the family y Keep clients personal hygiene well

analgesic y That therapy is given correctly

y To handle pain

y Preventing nasocomial infection y To minimalism organism to life y Hyperthermia is indicate the infection y To decrease risk for infection y To avoid nasocomial infection

y If specific indication the antibiotics can solve organism to cause infection

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IV. IMPLEMENTATION
NO Day/Date

Time

Dx 1

Implementation Determining pain history, location, duration, and intensity (P, Q, R, S, T)

Evaluation measures Client says little pain with a pain scale is one ( middle pain) when held or sometimes just appears like an ant bite but rarely y client was lying in bed while sleep y Client looks calm and sleep with no pain complained Family seemed understand what nurse described

Signa ture

Thursday 08.00 /8 July 2010

11.00

Providing distraction technique to do fun activity for the client Teach families about how to handle pain such as take deep breath, warm compresses, watching television or listening to the music Monitoring vital signs

11.20

12.00

12.30

13.00

Provide the opportunity for clients to express her feeling Provide information about the strong and accurate prognosis and explain treatment, the purpose and side effects

Friday,9 July 2010

14.30

Evaluating therapy of surgery (post op removal tumor excision) with determining the PQRST)

TTV was found normal, y Blood pressure: 120/70 mmHg y Pulse: 89 times/minute y Temperature: 36,1 0 C y Respiratory Rate: 24 times/ minute Client says that she does not understand about her present disease y Client say can understand what is described by the nurse and not worry again with the continuation of the disease y Client seem able to answer / repeat what nurses described y Client seem trust to nurse fully y Clients seemed calm and no longer anxious (scale 0) y client says pain in the left side of the breast due to the surgical procedure with pain scale is 2 ( middle pain

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14.40

Taught to take deep breath every pain is coming

17.30

Observe a post op removal tumor excision suture

17.40

18.40

Advice the client to report if there is infection signs or problem at her wound Observe the vital signs and general condition of the client

), the time is uncertain, such as pulse Clients say relaxation techniques with take deep breath is very effective in relieving pain y look Hipapix closes the stitches clean and white color y Stitches on the left side of the breast with the diameter 2 cm and long 6 cm y Clients said there was no interference with the position of the wound sutures Clients seem to cooperate with nurses Vital signs is normal: y Blood pressure: 120/80 mmHg y Pulse: 100 times/minute y Respiratory Rate: 23 times/minute y Temperature: 36 o C Client enjoyable at the bed Attached RL infusion in the right hand y Clients said the pain is still the same as yesterday that is pain in the breast with pain scale is 2 ( middle pain ) the time is rare but it does not feel uncomfortable anymore y Client looks calm and sitting in bed y Drugs which are: - Cefadroxil 2 times a day 5 days - Anzatax 3 times a day 3 days - Kalnex 3 times a day 3 days

21.00 3 Saturday, 08.00 10 July 2010

1 1

infusion set Evaluating pain

10.00

Provide Prescription Drug for the home and explain the rules of drinking.

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11.00

y Monitor progress wound of post-op excision of the tumor removal y Teaches client and families to maintain a client self personal hygiene and detect any signs of infection

y Client seems to understand clearly about the treatment that will be done at home. y Looks stitches is closed with hipapix and no signs of infection y Clients say there is no problem at stitches

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No 1

V. FINAL EVALUATION Day/Date Time DX Final evaluation Thursday 13.30 1 S: Client says little pain with a pain scale is one ( middle pain) when held or sometimes just appears 8 July like an ant bite but rarely 2010 O: - Client was lying in bed while sleep - Client looks calm and sleep with no pain complained - TTV was found normal, y Blood pressure: 120/70 mmHg y Pulse: 89 times/minute y Temperature: 36,1 0 C y Respiratory Rate: 24 times/ minute A: Pain problem partly is solved P: the intervention followed a night shift nurses - Instruct the client fasting starts at 12:00 tonight - Inform removal of the tumor excision surgery procedures performed on July 9 2010 at 11:00 pm 13.45 II S: Clients say to understand the information about the strong and accurate prognosis and treatment, the purpose and side effects O: y Client seem able to answer / repeat what nurses described y Client seem trust to nurse fully y Clients seemed calm and no longer anxious (scale 0) A: Anxiety problems is resolved P: Discontinued intervention Friday, 9 21.00 I S: July 2010 y client says pain in the left side of the breast due to the surgical procedure with pain scale is 2 ( middle pain ), the time is uncertain, such as pulse y Clients say relaxation techniques with take deep breath is very effective in relieving pain O: y Attached RL infusion in the right hand y Vital signs is normal: - Blood pressure: 120/80 mmHg - Pulse: 100 times/minute - Respiratory Rate: 23 times/minute - Temperature: 36 o C y Client enjoyable at the bed A: Pain problem partly is solved

Signature

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P: continued intervention - Evaluation of pain - Give doctor prescription of drug for at home and explain the rules of drinking. 21.15 2 S: y Clients said there was no interference with the position of the wound sutures O: y Clients seem to cooperate with nurses y look Hipapix closes the stitches clean and white color y Stitches on the left side of the breast with the diameter 2 cm and long 6 cm A: Risk for infection problem partly is solved P: y Monitor progress wound of post-op excision of the tumor removal y Teaches client and families to maintain a client self personal hygiene and detect any signs of infection S: Clients said the pain is still the same as yesterday that is pain in the breast with pain scale is 2 ( middle pain ) the time is rare but it does not feel uncomfortable anymore O: y Client seems to understand clearly about the treatment that will be done at home yDrugs which are: - Cefadroxil 2 times a day 5 days - Anzatax 3 times a day 3 days - Kalnex 3 times a day 3 days A: Pain problem partly is solved P: Discontinued intervention, the patient returned S: Clients say there is no problem at stitches O: Looks stitches is closed with hipapix and no signs of infection A: risk for infection problems is resolved P: Discontinued intervention, the patient returned

Saturday, 10 July 2010

11.25

11.30

II

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