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Republic of the Philippines

UNIVERSITY OF NORTHERN PHILIPPINES
Tamag, Vigan City
2700 Ilocos Sur
College of Nursing
Website: www.unp.edu.ph Mail: unp_nursingvc@yahoo.com
CP# 09177148749, 09175785986

A CASE STUDY ON

BREAST CANCER: STATUS POST

MODIFIED RADICAL MASTECTOMY RIGHT

In Partial Fulfillment of the Requirement in

Related Learning Experience
(Metro Vigan Hospital)

Submitted by:
LESTER PAUL R. SIVILA

Submitted to:
LORAINE R. RAMOS, MAN
Clinical Instructor
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TABLE OF CONTENTS

I. INTRODUCTION AND OBJECTIVES..........................................................................３

General Objectives:....................................................................................................４
Specific Objectives:....................................................................................................４
II. PATIENT’S PROFILE.......................................................................................................5
III. NURSING HISTORY OF PAST AND PRESENT ILLNESS..........................................6
a. History of Present Illness.....................................................................................6
b. History of Past Illness..........................................................................................6
c. Family Health History..........................................................................................6
IV. PEARSON ASSESSMENT...............................................................................................7
V. DIAGNOSTIC PROCEDURES
a. Ideal....................................................................................................................11
b. Actual.................................................................................................................11
VI. ANATOMY AND PHYSIOLOGY OF THE ORGAN INVOLVED..............................14
VII. PATHOPHYSIOLOGY
a. Algorithm...........................................................................................................17
b. Explanation........................................................................................................18
VIII. MANAGEMENT
a. Medical and Surgical Management....................................................................18
b. Nursing Care Plan..............................................................................................21
c. Promotive-Preventive Management...................................................................24
IX. DRUG STUDY.................................................................................................................25
X. DISCHARGE PLANNING..............................................................................................29
XI. UPDATES........................................................................................................................32
XII. BIBLIOGRAPHY............................................................................................................35
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I. INTRODUCTION AND OBJECTIVES

Breast cancer originates in your breast tissue. It occurs when breast cells mutate
(change) and grow out of control, creating a mass of tissue (tumor). Like other cancers, breast
cancer can invade and grow into the tissue surrounding your breast. It can also travel to other
parts of your body and form new tumors. When this happens, it’s called metastasis
(Cleveland Clinic, 2022).

Worldwide, breast cancer is the most frequently diagnosed life-threatening cancer in

women. In many less-developed countries, it is the leading cause of cancer death in women;
in developed countries, however, it has been surpassed by lung cancer as a cause of cancer
death in women. In the United States, breast cancer accounts for 30% of all cancers in women
and is second only to lung cancer as a cause of cancer deaths in women (Chalasani, 2022).

In its early stages, breast cancer may not cause any symptoms. In many cases, a tumor
may be too small to be felt, but an abnormality can still be seen on a mammogram. If a tumor
can be felt, the first sign is usually a new lump in the breast that was not there before.
However, not all lumps are cancer. Each type of breast cancer can cause a variety of
symptoms. Many of these symptoms are similar, but some can be different. Symptoms for the
most common breast cancers include: a breast lump or tissue thickening that feels different
from surrounding tissue and is new, breast pain, red or discolored, pitted skin on the breast,
swelling in all or part of your breast, a nipple discharge other than breast milk, bloody
discharge from your nipple, peeling, scaling, or flaking of skin on your nipple or breast, a
sudden, unexplained change in the shape or size of your breast, inverted nipple, changes to
the appearance of the skin on your breasts, and/or a lump or swelling under your arm
(Selchick, 2022).

Brought to Metro Vigan Hospital, patient PJM, a 65-year-old woman, was diagnosed
with breast cancer and had warning indications of tenderness, swelling and redness of her
breast, sore or itchy rashes on nipple, flaking skin in the nipple area, and pain in any place of
her breast. She is currently residing in Nalasin, Sto. Domingo, Ilocos Sur. Consultation was
sought and surgery was scheduled, hence admission. The client stayed on the hospital for 8
days.
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GENERAL OBJECTIVES:
The general objective of this case study is to learn in-depth knowledge about breast
cancer and modified radical mastectomy. To learn skills that can utilize and link to correct
nursing management and how the student nurse can apply proper attitude toward a patient
who will undergo this kind of surgery.

SPECIFIC OBJECTIVES:
In order to meet the general objective, the nurse aims to:

 Establish a nurse-patient relationship and rapport to the patient.

 Interpret the patients’ gathered data.
 Accurately present a through general assessment of the client which includes physical
assessment and family history taking.
 Recognize the contributing factors associated in the development of the diagnosis.
 Present the complete PEARSON assessment of the patient.
 Discuss anatomy and physiology of the organ involved to the patient’s disease.
 Understand the pathophysiology and etiology of the case being presented.
 Efficiently provide appropriate and proper nursing diagnosis in line with the client’s
medical condition and skillfully formulate nursing care plans for the problem
identified.
 Formulate specific, measurable, attainable, realistic and time bounded nursing care
plan to aid the patient’s condition.
 Understand the role of drug therapy in managing the client related to the patient’s
diagnosis.
 Appropriately apply nursing interventions necessary for the patient’s condition in
reference with the learned theories and concepts of the disease.
 Formulate an exclusive discharge home care plan, provide health teachings and uplift
importance of lifestyle modification, rehabilitation and follow-up.
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II. PATIENT’S PROFILE

Name: Neri Imana

Age: 68

Gender: Female

Occupation: Housewife

Educational Attainment: College Graduate

Civil Status: Widowed

Nationality: Filipino

Address: Nalasin, Sto. Domingo, Ilocos Sur

Religion: Roman Catholic

CC: Deep aching pain on her right breast awakening her at night.

Date Admitted: October 11, 2022

Admitting Diagnosis: Invasive Ductal Cancer, Right Breast

Attending Physician: Dr. Lahoz

Source of Information: Patient and significant other

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III. NURSING HISTORY OF PAST AND PRESENT ILLNESS

a. History of Present Illness

Patient Imana, a 68 year-old housewife, came to the hospital with complaints of Deep
aching pain on her right breast. She was admitted at Metro Vigan Hospital ward at 3pm.
During admission, vital signs were as follows: blood pressure of 160/90 mmHg, heart
rate of 89 bpm, respiratory rate of 20cpm, and a temperature of 36.5C. An oxygen saturation
of 97% was also recorded. Upon performing complete physical exam, ulcerated breast mass
on her right breast which was tender and swollen were also reported. Pain level rated as 9/10.
She was diagnosed with Invasive Ductal Cancer, Right Breast by Dr. Lahoz her attending
physician.

b. History of Past Illness

The client had undergone previous operations, cholecystectomy in 2014 and excision
of breast mass in 2019. No known allergies to medications and foods. The client does not
consume alcohol in a regular basis, only occasionally. She also does not smoke. Patient
Imana also had his immunization profile completed as a child. The patient also reported that
she used contraceptive pills before.
Past illnesses reported were hypertension, increased blood sugar, hyperthyroidism,
Acid Peptic Disease. Also experienced common illness such as, headache, nausea, rashes and
pain around the nipple. OTC medications such as Paracetamol for headaches, nausea, and
soreness around the breast, and Benadryl for nipple rashes, can help. In addition, they
supplement it with increasing water intake, eating a balanced diet of meat and vegetables, and
taking a rest. However, if conditions complicate, they immediately seek help from the nearest
health care facility.
c. Family Health History
The client reported that they do have a family history of breast cancer on both sides of
the family. The common illnesses experienced by the family are coughs and cold, fever, head
ache and body pain. They manage it with OTC drugs like paracetamol for headache and
fever, carbocisteine for cough, bioflu for colds and acetaminophen for muscle pain. These
drugs are reported to be effective but they seek medical assistance when this conditions
worsen. They also use herbal medicines as alternatives and visit folk healers.
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IV.
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V. PEARSON ASSESSMENT

ASSESSMENT DAY 1 DAY 3 DAY 4

October 11, 2022 March 13, 2022 March 14, 2022
Admission/Pre-Operation Operation - Post-Operation Post-Operation
Physiological/ Appearance Appearance Appearance
Psychosocial  Awake  Awake  Awake
 Wearing pajamas  Wearing hospital gown  Wearing hospital gown
 Hair slightly disheveled  Hair slightly disheveled  Hair slightly disheveled
 Facial grimacing  Facial grimacing  Slight facial grimacing
 Slightly diaphoretic  No discoloration of her  No discoloration of her
 No discoloration of her conjunctiva, oral mucosa, and conjunctiva, oral mucosa, and
conjunctiva, oral mucosa, and nail beds nail beds
nail beds  Weakness is still evident  Weakness is still evident
 Weakness is evident  Presence of surgical wound on
Behaviour her right breast due to surgery
Behaviour  Guarding behaviour done
 Guarding behaviour  Irritated
 Irritated  Restless Behaviour
 Restless  Participative to planned care  Less irritated
 Participative to planned care  Compliant to instructions and  Restless
 Compliant to instructions and medication administration  Participative to planned care
medication administration  Compliant to instructions and
Motor medication administration
Motor  Decreased strength and
 Decreased strength and endurance Motor
endurance  Can still do active ROM  Decreased strength and
 Strained movement endurance
 Can still do active ROM  Slightly passive ROM initially
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Speech Speech Speech

 Speaks well and coherently but  Speaks well and coherently but  Speaks well and coherently but
weakness is evident weakness is still evident slight weakness is evident
 Able to rate pain as 9/10  Able to rate pain as 9/10  Able to rate pain as 7/10
 Able to describe pain as deep,  Verbalizes anxiety towards  Verbalizes anxiety towards
aching pain on the right breast surgery removal of her right breast
and the area surrounding it
 Responds well during health
interview Affect Affect
 Appears to be optimistic to her  Appears to be trying to adapt
treatment on having no right breast
Affect  Though she became anxious
 Appears to be optimistic to her and nervous few minutes
treatment before operation
 Though slightly anxious and
nervous at times
 Needs to have company for
distraction
Elimination Gastrointestinal Gastrointestinal Gastrointestinal
 Nauseous but did not vomit  There was no elimination  Nauseous but no vomiting
 There was no elimination activity before surgery episodes
activity before surgery  Defecated once in the
afternoon
Renal Renal
 Urinated twice  Urinated once
 Pale yellow urine  Pale yellow urine Renal
 Adequate urine output  Scanty urine output  Urinated five times
 Pale yellow urine
 Adequate urine output
Activity/Rest Activity Activity Activity
 Sleeps most of the time  Sleeps most of the time  Limited physical activity
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 Watches on her phone or the  Watches on her phone or the  Early ambulation initiated
TV when she is awake TV when she is awake more actively
 Walks around her room
assisted by her significant other Rest/Sleep Rest/Sleep
 On modified high back rest  On modified high back rest
Rest/Sleep  Disturbed sleep at night  Reported to have better rest
 Able to sleep 5-6 hours but  Woke up and whining due to  Able to sleep a good 7 night
with interruptions pain in the affected areas hours with only few minutes
 Woke up and whining due to  Sipping water somehow of interruption for care
pain in the affected areas relieves pain and induces sleep
 Sipping water somehow
relieves pain and induces sleep
Safety and Security  Vital signs noted as follows:  Closely monitored for effects  Closely monitored for effects
blood pressure of 160/90 of anesthesia of anesthesia
mmHg, heart rate of 89 bpm,  Vital signs noted to be stable  Vital signs noted to be stable
respiratory rate of 20cpm, and  Input and output were closely  Input and output were closely
a temperature of 36.5C. assessed assessed
 Input and output were closely  Side rails are raised  Side rails are raised
assessed  Antibiotics given to prevent  Antibiotics given to prevent
 Side rails raised infection infection
 Antibiotics given to prevent  Surgery wound was kept clean  Surgery wound was kept clean
infection and dry and dry
 IV insertion site was free of  Drainage tube was patent  Drainage tube was patent
inflammation  IV insertion site was free of  IV insertion site was free of
 Analgesics and ice pack were inflammation inflammation
administered for pain relief  Analgesics and ice pack were  Analgesics and ice pack were
 Instructed patient to be on high administered for pain relief administered for pain relief
back rest  Instructed patient to be on high  Instructed patient to be on high
 Instructed significant other to back rest back rest
watch over and assist patient
when moving
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Oxygenation  Oxygen saturation level at 97%  Oxygen saturation level at 96%  Oxygen saturation level at 98%
upon admission  Respiratory rate of 19 cpm  Respiratory rate of 18 cpm
 Respiratory rate of 20 cpm  Patient was ordered to be on  Patient on O2 inhalation at 3
 No signs of difficulty breathing O2 inhalation at 3 LPM until LPM until awake
awake
Nutrition  Good skin turgor  Good skin turgor  Good skin turgor
 No solid foods post-midnight  DAT instructed when fully  DAT instructed
instructed awake  No allergy noted to foods and
 No allergy noted to foods and  No allergy noted to foods and medications
medications medications
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VI. DIAGNOSTIC PROCEDURES

a. IDEAL
• Breast Ultrasound – a machine that uses sound waves to make pictures, called
sonogram, of areas inside the breast.
• Mammogram – is and x-ray of the breast, this are commonly used to screen breast
cancer. If an abnormality detected on a screening mammogram, your doctor may
recommend a diagnostic mammogram to further evaluate that abnormality.
• Breast Magnetic Resonance Imaging – a kind of body scan that uses a magnet
linked to a computer. The MRI scan will make detailed pictures of areas inside the
breast.
• Biopsy – this is a test that removes tissue or fluid from the breast to be looked at a
microscope and do more testing.

b. ACTUAL

 THYROID HORMONES (CLIA)

TEST RESULT NORMAL VALUE

TSH 2.213 0.400 - 4.500 uiU/mL
T3 0.822 0.690 - 2.150 ng/mL
T4 39.23 (L) 52,000 – 127,000 ng/mL

Findings for CBC

Though the T4 was noted below the normal range, it is still not a critical value that is
anticipatory to any thyroid complications.

 COMPLETE BLOOD COUNT (CBC)

TEST RESULT NORMAL VALUE

Hematocrit 40 F: (39-47%)
Hemoglobin 134 F: (120 – 160g/L)
WBC 6.3 4,500 – 11,000 x 10 9/L
RBC 4.21 4,200 – 5,400
Platelet 275 150,000 – 450,000 x 10 9/L
MCV 96.7 80,000 – 97,000 femtoliter/cell
MCH 31.8 26,000 – 33,000 picogram/cell
MCHC 32.9 31,000 – 35,000 %
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Findings for CBC

No significant abnormal result were seen on the CBC report.

 BLOOD UREA NITROGEN, CREATININE

TEST RESULT NORMAL VALUE

BUN 4.1 2,500 – 6,500 MMOL/L
CREATININE 61 53,000 – 97,000 MMOL/L

Findings for BUN and Creatinine

No significant abnormal result were seen on the laboratory report for BUN and creatinine.

 URINALYSIS

TEST RESULT NORMAL VALUE

Microscopic Examination
Transparency Slightly Turbid
Color Yellow

Chemical Examination
Specific Gravity 1.005 (L) 1.016 – 1.022
pH 8.0 6-8
ALBUMIN Negative
Nitrites Negative
Blood (Hemoglobin) Negative
Sugar Negative

Amorphous
Urates
Phosphates Rare

Microscopic Examination
Pus cell 1-3/HPF
Red Blood Cells 1-3/HPF
Mucus Threads
Epithelial Cells Rare
Bacteria

Findings for Urinalysis

No significant remarks were noted on the urinalysis report.

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 SARS-COV 2 TESTS

EXAMINATION RESULT
SARS-COV 2
NEGATIVE
Qualitative Antigen Rapid Test
SARS-COV 2 Viral RNA Testing
NEGATIVE
By Real Time Polymerase Chain Reaction Detection

 CHEST X-RAY: POSTEROANTERIOR VIEW

RADIOGRAPHIC INTERPRETATION
No definite active lung infiltrates seen.
The heart is not enlarged.
The aortic knob is sclerotic.
The diaphragm is normal in position and contour.
Visualized bones are intact.
IMPRESSION
ATHEROMATOUS AORTA

 EXCISION BIOPSY, RIGHT BREAST MASS

INVASIVE DUCTAL CARCINOMA, NOTTINGHAM HISTOLOGIC

GRADE II WITH DUCTAL CARCINOMA-IN-SITU (30%), COMEDO,
SOLID AND CRIBRIFORM PATTERNS.
TUMOR SIZE: 2.5 cm.
TUMOR IS AT THE RESECTION MARGIN.

SUGGEST IHC (ER, PR, Her2), Block A1.

Gross/Microscopic Description:
Specimen consist of a firm mass with irregular surface measuring 2.5x1.5x1.5cm. Cut
surface shows a yellow white mass with irregular borders measuring 2x1x1cm. There is thin
rim of fatty tissues at the periphery. No necrosis noted. All seven sections, block two (A1-
A2).
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 THYROID ULTRASOUND

SONOGRAPHIC INTERPRETATION
The right thyroid lobe measures 4.9 x 1.4 x 1.4 cm. The left thyroid lobe measures 5.1 x 1.6 x
1.0 cm. There are several solid and complex nodules in both lobes (Right = 0.2 to 1.7 cm;
Left = 0.4 to 1.1 cm). The rest of the parenchyma is homogenous and medium level.

The isthmus is unremarkable.

The adjacent vascular structures are not unusual.

Hypoechoic nodules are noted in both lateral neck measuring 1.2 cm and less in the right
while those in the left measures 1.5 cm and less.

IMPRESSION
- SOLID AND COMPLEX NODULES, BOTH THYROID LOBES
- PROMINENT CERVICAL LYMPH NODES

VII. ANATOMY AND PHYSIOLOGY OF THE ORGAN INVOLVED

Figure 2. The Breast and Its Parts

The anatomy of the breast reflects its unique function: the production of milk for

lactation (breast feeding). The tissue's epithelial component is made up of lobules that

produce milk and link to ducts that lead to the nipple. The cells that make up the lobules and
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terminal ducts are the source of the majority of breast malignancies. The background fibrous

tissue and adipose tissue (fat) that make up the majority of the breast contain these lobules

and ducts. The male breast structure is virtually comparable to that of the female breast,

with the exception that male breast tissue lacks the specialized lobules because males do not

have a physiological necessity for milk production.

The adult breast is anatomically located on the pectorals muscle (the "pec" chest

muscle), which is located atop the ribcage. From the edge of the sternum (the firm flat bone

in the middle of the chest) to the maxillary line, the breast tissue stretches horizontally (side-

to-side) (the center of the axilla, or underarm). The "axillary tail of Spence," a tail of breast

tissue that extends into the underarm area, is significant because a breast cancer can form in

this axillary tail, even if it does not appear to be contained within the actual breast.

Fascia is a thin layer of connective tissue that surrounds the breast tissue. The

superficial layer of this fascia resides just beneath the skin, whereas the deep layer lays just

atop the pectorals muscle. The skin that covers the breasts is similar to skin found elsewhere

on the body, with sweat glands, hair follicles, and other characteristics in common. When

completing a breast exam, a doctor will look at the skin as well as the breast tissue.

Blood Supply and Lymph Nodes

The internal mammary artery, which runs beneath the primary breast tissue, is the
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main source of blood flow for the breast. The breast tissue receives nutrients, such as

oxygen, from the blood supply. The lymphatic veins of the breast drain into lymph nodes in

the opposite direction of the blood supply. Breast tumors metastasis or spread to lymph

nodes through these lymphatic arteries. The majority of lymphatic vessels travel to the

axillary (underarm) lymph nodes, whereas a smaller number travel to the internal mammary

lymph nodes, which are located deep within the breast.

It's crucial to understand lymphatic drainage because when breast cancer

metastasizes, it usually starts with the first lymph node in the chain of lymph nodes. The

"sentinel lymph node" is a lymph node that a surgeon may remove to look for metastases in

a patient with breast cancer.

Because of the hormonal changes that occur during pregnancy and lactation, the

breast tissue undergoes several additional alterations.

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VIII. PATHOPHYSIOLOGY

a. Algorithm

Figure 2. Pathophysiology of Breast Cancer

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b. Explanation of the Schematic Diagram Presentation of the Pathophysiology

There is still no known etiology for the disease. However, old age, gender, family
history, lifestyle and diet can predispose a person from having breast cancer. It begins when
somatic mutations in the DNA occurs leading to the activation of oncogene and the
deactivation of the tumor suppressor gene. This would then allow neoplasm to form in the
breast. If primary tumor is treated via multiple methods such as surgical removal of the
affected parts, pharmacological interventions, chemotherapy, or radiotherapy. If successfully
managed and treated, cancer cells get destroyed. On the other hand, once a tumor starts to
become invasive, inflammatory cytokines are released which then causes local vasodilation in
the affected area. More blood accumulates in the skin of the breast which is now manifested
through diffused breast erythema or reddening of the skin. In addition, local nociceptors
becomes activated causing pain. Moreover, if tumor progresses to develop, it starts to invade
or metastasize to adjacent areas or other organ systems. This results to major organ functions
to be compromised leading now to multiple-organ dysfunction, shock, and eventually death.

IX. MANAGEMENT

A. MEDICAL AND SURGICAL MANAGEMENT

MEDICAL MANAGEMENT
a. Ideal
The treatment begins the order to put the patient in NPO in preparation for the
surgery. An intravenous drip is used to hydrate the patient. Antibiotics such as cefuroxime
and metronidazole given intravenously are administered early to help kill bacteria and
prevent spread throughout the abdomen and occurrence of post-operative complications.
Equivocal cases may be difficult to assess with antibiotic treatment thus serial examinations
might be ordered.

Pain may become severe. Strong pain medications are recommended for pain
management before surgery. Morphine is generally the standard of care in adults and children
in the treatment of pain from appendicitis prior to surgery.

b. Actual
Patient Imana was rushed at Metro Vigan Hospital Emergency Room at 3pm, October
11, 2022. She complained of deep, aching pain on her right breast awakening her at night.
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She was admitted in the ward section. She was diagnosed with Invasive Ductal Cancer, Right
Breast by Dr. Lahoz.

The client was also restricted from eating and drinking in preparation for surgery
post-midnight. A Plain LR 1 liter was given intravenously to run for 8 hours. Antibiotic
therapy (cefuroxime) along with analgesic was also administered in preparation for surgery.
Ice pack was also used to help relieve pain felt by the patient. Rest was provided, attended
care needs, and close monitoring was done prior surgery.

After the surgery, she was closely monitored for the effects of the anesthesia. Surgical
wound was also kept clean and dry. She was on continued meds as ordered by the doctor. She
was also observed for any signs of anxiety with regards to her loss of breast.

SURGICAL MANAGEMENT
a. Ideal
The overall goal of an MRM is to remove all or most of the cancer present while
preserving as much of the healthy skin tissue as possible. This makes it possible to perform
an effective breast reconstruction after the wound healed properly.

Preparation typically involves stopping certain medications or supplements. For an

MRM, a ptient will be placed under general anesthesia.

The entire procedure commonly takes between 2 to 3 hours. The doctor will then
mark the patient’s chest to prepare for incisions. Making one incision across the chest, the
doctor will carefully pull the skin back far enough to remove the breast tissue. They’ll also
remove most of the lymph nodes under the arm. Once the lymph nodes are removed, the
doctor will examine them to determine whether cancer has spread to them or through them to
other areas of the body. The doctor will also place thin plastic tubes in the patient’s breast
area to drain any excess fluid. They may remain in the patient’s chest for up to 1 to 2 weeks.

Recovery times differ from one person to the next. Typically, people remain in the
hospital for 1 or 2 days. In some cases, the doctor may recommend radiation
therapy or chemotherapy following the mastectomy procedure.

It is also important to keep the surgical area clean and dry. The patient will be given
specific instructions on how to care for the wound site and how to properly bathe.
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Pain is normal, but the amount of discomfort the patient might experience may
vary.The doctor may suggest pain relievers. If so, only take what’s prescribed. Some pain
medications can cause complications and slow the healing process.

Constipation is a common aftereffect of surgery. You may need to make temporary

changes to ease the symptoms, such as modifying the patient’s diet or taking stool softeners.

Lymph node removal can cause the patient arm to feel stiff and sore. The doctor may
recommend certain exercises or physical therapy to increase movement and prevent swelling.
Performing these exercises slowly and regularly can prevent injury and complications.

If the patient reports that he/she begins to experience more discomfort or if the patient
notices the healing is at a slower pace, schedule an appointment with the doctor.

b. Actual

Due to presence of invading cancer cells as indicated in the CT scan imaging result
and findings, an informed consent for surgery was obtained from the client. She was
scheduled for surgery at 9 am on October 13, 2022 and was given a general anesthesia an
hour before surgery. Endotracheal intubation was done to assist breathing during surgery. An
NG tube was also inserted to suction air and fluid from the stomach to prevent vomiting. The
patient undergone modified radical mastectomy on her right breast. The surgery was
successful and the closing incision was done without any untoward complications. A
drainage tube was inserted and was left for 3 days.
Patient RA was then then transferred at the post-anesthesia care unit 12 PM post-
surgery. Vital signs were closely monitored in order to detect anesthesia and/or surgery
related complications.

After the patient was completely awake, she was moved into a hospital room to
recover. Intravenous fluids were infusing well. Pain management was continued. Antibiotics
was also continued post-surgery to treat possible infections and was discontinued when
patient became afebrile and WBC count normalized. Bowel sounds where routinely assessed.
Clear liquids were allowed the day after the surgery and advanced to a regular diet when
peristalsis returned. Fiber supplement (Metamucil) was also given to help restore normal
bowel function. Patient remained in the hospital for 3 days. Goals of his stay included
monitoring vital signs, preventing infection, pain management, fluid and electrolytes
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management, restoration of normal bowel function, wound care, adequate nutrition,

ambulation, and psychosocial support.
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B. NURSING CARE PLANS

SCIENTIFIC
ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION
BACKGROUND
SUBJECTIVE: Impaired skin Modified radical October 13, 2022 Independent October 14, 2022
“Medyo nagatel no integrity related mastectomy done 12 PM 1.Inspect dressings 1.To monitor for signs of 12 AM
dadduma to surgical anteriorly and bleeding and drainage.
nakkong,” as removal of skin Short-Term Goals posteriorly for 2.Reduces pressure on
verbalized by the or tissue as characteristics of compromised tissues,
patient. evidence by Cutting through the After 12 hours of drainage. which may improve After 12 hours of
presence of skin and other nursing 2.Encourage wearing circulation and healing nursing
surgical incision, layers interventions, of loose-fitting or and minimize interventions,
OBJECTIVE: redness and patient will be able non-constrictive lymphedema. patient was able to
 Presence of itchiness on the to maintain good clothing. 3.To promote maintain good
surgical incision surgical wound. wound healing and 3.Educate patient and independence and wound healing
Break on skin’s faster healing
 Redness and be free from significant others however slight
integrity
itchiness on the erythema and how to properly erythema and
surgical wound itchiness. take care of the itchiness on the
area surgical wound and area is still present.
 Slightly warm to Impaired Skin dressing.
touch Integrity
Dependent: Goal partially met.
4.Given as a prophylaxis
4.Administer
and to enhance healing
antibiotics as
ordered.

Collaborative:
5.Collaborate with 5.To promote faster
dietician and recovery and tissue
nutritionist healing
regarding to proper
diet and nutrition
intake.
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SCIENTIFIC
ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION
BACKGROUND
SUBJECTIVE: Altered body Presence of cancer October 13, 2022 Independent October 14, 2022
“Maikawa nak ken image related to on the right breast 12 PM 12 PM
ammok haan mastectomy as 1.Encourage 1.To allow the patient
maisublin,” as evidenced by Short-Term Goals verbalization of to express herself After 24 hours of
verbalized by the loss of right positive and negative and release tension nursing
patient. breast and Removal of right After 24 hours of feelings about actual on feelings interventions and
negative feelings breast through nursing interventions or perceived change. 2.To facilitate good psychosocial
OBJECTIVE: about body. MRM and psychosocial 2.Maintain therapeutic patient-nurse support, patient
 Loss of right support, patient will communication and interaction and also was able to:
breast be able to: demonstrate positive gain trust to  demonstrate
 Appears to be  demonstrate caring during cooperate. movement
Absence of a body activities. 3.To help the patient
conscious to the movement towards towards
part (right breast) 3.Teach patient gain back self-
affected part acceptance; and acceptance;
 Restless  set realistic goals adaptive behaviour confidence by and
 Teary eyes and actively like using adaptive slowly adapting to  set realistic
Altered Body participate in equipment like change. goals and
Image planned care. breast pads. 4.To make the client actively
4.Help patient identify focus on activities participate in
coping and and healing rather planned care.
diversional activities. than dwelling on
her condition. Goal met.
Collaborative:
5.Collaborate with
support groups to 5.To slowly integrate
help patient cope. her back to society.
 26

SCIENTIFIC
ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION
BACKGROUND
SUBJECTIVE: Risk for Break in the skin October 13, 2022 Independent October 13, 2022
infection as integrity 12 PM 1.Closely observe 1. To prevent and detect 2 PM
evidenced by a for signs of any progressing
OBJECTIVE: break in skin Short-Term Goals infection. infection as early as After 2 hours of
 Presence of integrity. 2.Empty and re- possible nursing
surgical wound Risk for pathogens After 2 hours of establish negative 2.Negative pressure interventions
to invade nursing pressure in the pulls fluid from the postoperatively,
interventions drain. incisional area, which patient was free
postoperatively, 3.Encourage proper facilitates healing. from any signs of
patient will be free hand hygiene. 3.Primary prevention of infection.
Risk for infection infection
from any signs of 4.Instruct on proper
infection. wound care. 4.For first line defense
against nosocomial Goal met.
Dependent: infections or cross-
5.Administer antibio contaminations.
tics as ordered. 5.To boost the immune
system
Collaborative: 6.To allow earlier
6.Monitor blood detection of possible
tests and urine infection or
output regularly. complications.
 27

C. PROMOTIVE-PREVENTIVE MANAGEMENT
PROMOTIVE

Anyone can spread the word about the risk of breast cancer, and aid in researching a cure
such as

• Get moving – joining a breast cancer race can be a fun way to get some exercise
connect with other people affected by breast cancer and contribute to a great cause.
• Wear pink –Wearing or displaying pink gear contributes to cancer research, and
reminds people around you that it’s important to help fight breast cancer. National
Breast Cancer Awareness Month is October.
• Reach out through social media – use social media platforms to raise awareness of
breast cancer.
• Involved local businesses to contribute money to breast cancer research and suggest
to wear pink for a day in supporting breast cancer awareness. A portion of the said
fundraising proceeds to breast cancer related organization.

PREVENTIVE
There is no way to prevent breast cancer. However, a person can take steps to
significantly reduce their risk.

These include:

 limiting alcohol consumption, for people who drink

 having a healthy diet with plenty of fresh fruit and vegetables
 getting enough exercise
 maintaining a moderate body mass index

A person who is considering using hormone replacement therapy after menopause may
wish to discuss this with a healthcare professional.
 28

X. DRUG STUDY

NAME OF DRUG INDICATIONS: MECHANISM OF ADVERSE EFFECTS NURSING RESPONSIBILITIES

ACTION
Generic Name:  To manage hypertension  Monitor blood pressure, apical and
propranolol Blocks stimulation
 CNS: Anxiety, depression,
radial pulses, fluid intake and
dizziness, drowsiness, fatigue,
CONTRAINDICATIONS: of beta1-adrenergic output, daily weight, respiration,
Brand Name: fever, insomnia, lethargy,
 Asthma (myocardial) and and circulation in extremities
Apo-Propranolol nervousness, weakness
 Cardiogenic shock beta2-adrenergic before and during therapy.
(CAN), Detensol  Greater than first-degree (pulmonary,  CV: AV conduction disorders,  Because drug’s negative inotropic
(CAN), Inderal, AV block vascular, and cold limbs, heart failure, effect can depress cardiac output,
Inderal LA,  Sick sinus syndrome, or uterine) receptor hypotension, sinus bradycardia monitor cardiac output in patients
InnoPran XL,  Sinus bradycardia (unless sites. This action  EENT: Dry eyes, laryngospasm, with heart failure, particularly
Novopranol (CAN), pacemaker in place) decreases cardiac those with severely compromised
nasal congestion, pharyngitis
pms Propranolol output, slows heart left ventricular dysfunction.
 Heart failure (unless  GI: Abdominal pain,
(CAN) rate, and reduces  Be aware that propranolol can
secondary to constipation, diarrhea, nausea,
tachyarrhythmia blood pressure. mask tachycardia in
Classification: vomiting hyperthyroidism and that abrupt
responsive to
Antihypertensive  GU: Impotence, Peyronie’s withdrawal in patients with
propranolol)
 Hypersensitivity to disease, sexual dysfunction hyperthyroidism or thyrotoxicosis
Dosage:
propranolol or its  HEME: Agranulocytosis, can cause thyroid storm.
10 mg
components nonthrombo cytopenic  Instruct patient to take propranolol
Frequency: purpura, thrombocytopenic at the same time every day.
OD purpura  Caution patient not to change
dosage without consulting
 MS: Muscle weakness, prescriber and not to stop taking
Route:
myopathy, myotonia drug abruptly.
PO
 RESP: Bronchospasm, dyspnea,  Advise patient to notify prescriber
respiratory distress, wheezing immediately if she has shortness of
 SKIN: Alopecia, erythema breath.
 29

multiforme, erythematous rash,  Inform patient the purpose of the

exfoliative dermatitis, medication and dosage and
psoriasiform rash, Stevens- frequency.
Johnson syndrome, toxic  Provide a calm and comfortable
epidermal necrolysis, urticaria environment.
 Other: Anaphylaxis, flu-like  Provide psychosocial support.
symptoms, systemic lupus-like  As appropriate, review all other
reaction significant and life-threatening
adverse reactions and interactions,
especially those related to the
drugs, tests, herbs, and behaviours
mentioned above.
 30

NAME OF INDICATIONS: MECHANISM OF ADVERSE EFFECTS NURSING RESPONSIBILITIES

DRUG ACTION
 To treat hyperthyroidism  CNS: drowsiness, Patient monitoring
Generic Name: Directly interferes headache, vertigo, neuritis,  Monitor CBC and liver and thyroid
propylthiouracil CONTRAINDICATIONS: with thyroid synthesis paresthesia function tests.
 Hypersensitivity to drug by preventing iodine  Assess for signs and symptoms of
Brand Name: or its components from combining with
 GI: nausea, vomiting,
hypothyroidism (cold intolerance,
Propyl-Thyracil thyroglobulin, leading diarrhea, epigastric distress
nonpitting edema, fatigue, weight gain, and
(CAN) to decreased thyroid  Hematologic: depression).
hormone level. agranulocytosis, leukopenia,  Monitor for severe rash, fever, jaundice, or
Classification: thrombocytopenia enlarged cervical lymph nodes. If present,
Antithyroid  Hepatic: jaundice, hepatic stop therapy and notify prescriber.
necrosis, liver failure
Dosage:
 Metabolic: hypothyroidism Patient teaching
50mg  Instruct patient to take with meals to reduce
 Musculoskeletal: joint
pain, myalgia GI upset.
Frequency:
 Teach patient to recognize and report signs
TID  Skin: rash, urticaria,
and symptoms of hypothyroidism and
pruritus, skin discoloration,
Route: jaundice.
alopecia, cutaneous
PO  Advise patient to discuss iodine intake (as
vasculitis
in iodized salt and shellfish) with
 Other: taste loss, fever, prescriber.
lymphadenopathy, parotitis,  Tell patient to avoid over-the-counter cold
edema remedies that contain iodine.
 Caution patient to avoid driving and other
hazardous activities until he knows how
drug affects concentration and alertness.
 As appropriate, review all other significant
and life-threatening adverse reactions and
interactions, especially those related to the
drugs and tests mentioned above.
 31

NAME OF INDICATIONS: MECHANISM OF ADVERSE EFFECTS NURSING RESPONSIBILITIES

DRUG ACTION
 To relieve mild to moderate  GI: Abdominal pain,  Monitor for pain and vital signs
Generic Name: pain; to manage moderate to Anaseran may act hepatotoxicity (possibly severe), appropriately.
paracetamol severe pain with adjunctive predominantly by nausea, vomiting  Assess for signs and symptoms of
opioid analgesics; to reduce inhibiting prostaglandin respiratory distress.
Brand Name: synthesis in the central
 HEME: Hemolytic anemia (with
fever  Advise patient to report difficulty
Anaseran nervous system (CNS) long-term use), leukopenia,
neutropenia, pancytopenia, breathing, nausea, vomiting, or
CONTRAINDICATIONS: and to a lesser extent, dizziness.
Classification: through a peripheral thrombocytopenia
 Hypersensitivity to  Provide ice pack to help reduce
Analgesic, acetaminophen or its action by blocking pain-  SKIN: Acute generalized pain.
antipyretic components impulse generation. exanthematous pustulosis,
 Inform patient the purpose of the
 Severe hepatic impairment The peripheral action jaundice, pruritus, rash,
Dosage: medication and dosage and
 Severe active liver disease may also be due to StevensJohnson syndrome, toxic
1g/10mL frequency.
inhibition of epidermal necrolysis, urticaria
 Provide a calm and comfortable
prostaglandin synthesis  Other: Anaphylaxis, environment.
Frequency: or to inhibition of the angioedema, hypersensitivity
q8 x 2 doses  Provide psychosocial support.
synthesis or actions of reaction, hypoglycemic coma
 As appropriate, review all other
other substances that
Route: significant and life-threatening
sensitise pain receptors to
IV adverse reactions and interactions,
mechanical or chemical
especially those related to the
stimulation.
drugs, tests, herbs, and behaviors
mentioned above.
 32

XI. DISCHARGE PLANNING

Upon discharge from Metro Vigan Hospital, the patient and her significant others
were given home care instructions which contains the following:

MEDICATIONS  The medications prescribed by the physician will be

continued or maintained for faster recovery/ healing
process.
 Instruct patient to comply to her take home medications
as follows:
 Paracetamol: 500mg 1 cap by mouth three times
a day, for one week.
 multivitamins (Enervon-C): 1 tab a day
 Instructed patient to take medications appropriately as
ordered by the physician.
 Follow scheduled appointment.
ENVIRONMENT  Instructed patient to provide a peaceful, relaxing, and
comfortable room.
 Instructed patient to provide a stress free environment
 Instructed to provide clean environment to prevent
lodging of infectious microorganisms.
 Changes in her environment can aid in her recovery by
making it easier for her to bathe, dress and prepare
meals while her muscles return to normal levels of
strength
TREATMENT  Advise patient to take home medications strictly as
prescribed.
 Increase oral fluid intake to avoid dehydration.
 Instruct patient to understand and follow discharge
instruction religiously and accurately.
 Reinforced proper surgical wound care.
 Emphasize to the patient and significant other the
importance of regular follow-up check-ups and as
 33

instructed by physician.
 Advise the patient and significant other to seek medical
advice if any strange or sudden complications arise.
HEALTH TEACHINGS Patient is advised to:
 Take her medications as prescribed strictly.
 Have an adequate rest.
 Practice slow deep breathing to promote relaxation and
prevent stress.
 Keep the incisions clean and dry.
 Wear loose-fitting clothes. This will help cause less
irritation around the incisions.
 Shower as normal. Gently wash around incisions with
soap and water. Don’t take a bath until incisions are
fully healed.
 Don’t lift anything unnecessarily heavy objects.
 Review information about medications to be taken at
home, including name, dosage, frequency and possible
side effects, discussed the importance of continuing to
take
 Instructed patient to avoid any strenuous activities, until
the incision completely healed.
 Notify MD if s/sx of infection noted. (ex: fever, chills,
redness around the incision, and any discharges.)
OUT PATIENT  The patient should attend her follow-up check-up in
order for the physician to see the progress of the patient
and to advise what to do.

 Remind the patient that even though she feels better, it

is important to have the doctor monitor his progress.

 Instruct patient to notify physician if there is any

undesired feeling about the disease.

DIET  Resume usual diet.

 Instructed patient to eat a nutritious diet, mainly green
 34

leafy vegetables.
 Advised patient the need to increase calories and
protein to regain weight and to continue healing.
 Encouraged increased fluid intake.
SAFETY AND SECURITY After discharge, the patient should be in a secure setting.
SPIRITUAL When it comes to moving higher, she should have the
backing of her loved ones. They should also seek God's help
through prayer. As she continues to fight for her life, pray
for strength and wisdom from God.
 Encourage the patient to continue to seek God’s
guidance and to continue to have a positive outlook in
life.
 Emphasize the importance of prayers in healing.
 Encourage the patient to pray for her fast recovery and
gave words of encouragement.
 Encourage patient to talk about her feelings with his
significant others. Plan to work through those feelings
together.
 35

XII. UPDATES

EDITORIAL: UPDATE OF CURRENT EVIDENCES IN BREAST CANCER

SURGERY

The modern breast surgeon should perform the choice of breast-conserving treatment
versus mastectomy based on breast volume to cancer volume ratio, multicentricity, presence
of mammographic microcalcifications, ability to achieve clear surgical margins and patient
wishes; a careful evaluation of the disease by clinical and radiological examination is crucial
to select the optimal local treatment.

BCS combined with adjuvant radiotherapy is now deemed the gold standard approach
for early stage breast cancer because it permits to preserve the breast without affecting
oncologic results; various prospective randomized studies have shown no significant
differences in disease-free and overall survival rates when comparing breast-conserving
treatment with mastectomy for early-stage breast cancer. BCS should always ensure the
complete surgical removal of the tumor with negative surgical margins and an adequate
aesthetic outcome followed by adjuvant radiotherapy to eradicate any residual disease. The
role of BCS has been also expanded to include some patients who would otherwise require
mastectomy to obtain appropriate tumor clearance thanks to the use of oncoplastic
techniques; these innovative procedures combine the principles of surgical oncology and
plastic surgery to remove larger amounts of breast tissue with safer margins while improving
aesthetic outcomes also with the use of filler biomaterials.

Neoadjuvant chemotherapy (NAC) is being used with increasing frequency in the

multidisciplinary treatment of patients with operable breast cancer. Several clinical trials have
proved that NAC permits to achieve essential benefits such as assessment in vivo tumor’s
chemosensitivity by monitoring response to therapy; downstaging of tumor favoring BCS
over mastectomy; reduction of excision volumes in patients with cancer who are already
candidates for BCS; downstaging of the axilla in order to avoid complete axillary dissection.

The locoregional treatment of metastatic breast cancer is largely reserved for

palliation in patients with significant symptoms from primary tumor. The efficacy of this
surgery is still controversial and the debate about resection of primary tumor in metastatic
breast cancer patients persists. Surgical treatment of primary breast cancer in metastatic
 36

setting could be an option after systemic therapies. Randomized prospective trials for each
immunophenotype are necessary in order to confirm this evidence.

Reference:

Franceschini, G., et al. (2022, June 24). Editorial: Update of Current Evidences In Breast
Cancer Surgery. Open Access. Retrieved January 2, 2023 from
https://www.frontiersin.org/articles/10.3389/fonc.2022.928467/full

BREAST IMPLANTS AFTER MASTECTOMY ASSOCIATED WITH VERY LOW

RISK OF LYMPHOMA
The incidence of a rare cancer, anaplastic large-cell lymphoma (ALCL), has surged in
recent years, possibly because of the growing use of textured breast implants. Considering
this trend, some breast cancer patients who undergo mastectomy may wonder if the benefits
of getting reconstructive implants are worth the risk of developing a second cancer.

A new Columbia study should make many women's decisions easier. The study found
that the risk of developing ALCL after reconstructive surgery is extremely low: Each year,
about 12 cases are expected to occur per 1 million women who've had reconstructive surgery.

According to lead author Connor J. Kinslow, MD, a resident in radiation oncology at

the Columbia University Vagelos College of Physicians and Surgeons, the risk of developing
ALCL is actually much lower than the risk of experiencing a relapse of breast cancer.

Based on their findings, they do not believe that women should be dissuaded from
having implant-based breast reconstruction after mastectomy solely due to the risk of ALCL.

The new study was designed to provide women with accurate information about risk
and is the first to look at rates of ALCL in breast cancer survivors who've had breast implants
after mastectomy.

The researchers used a national cancer registry to identify 57,000 women who had
undergone mastectomy with implant reconstruction for breast cancer or ductal carcinoma in
situ (an early, noninvasive stage of breast cancer) between 2000 and 2018. The median
follow-up time was seven years, and roughly 16,000 women were followed for at least 10
years.
 37

Though the study found that women who have had post-mastectomy breast
implants do have a higher risk of ALCL than women in general (each year, 0.3 cases are
expected per million in the general population).

David Horowitz, MD, assistant professor of radiation oncology at Columbia

University Vagelos College of Physicians and Surgeons noted that ALCL is a rare cancer.
Among the 57,000 women in the study, only five cases of ALCL were diagnosed over the
combined 421,000 years of follow-up.

Reference:

Columbia University Irving Medical Center. (2022, December 2). Breast Implants after
Mastectomy Associated With Very Low Risk of Lymphoma. Jama Network Open
Retrieved January 2, 2023 from https://medicalxpress.com/news/2022-12-breast-
implants-mastectomy-lymphoma.html
 38

XIII. BIBLIOGRAPHY

WEBSITES
Chalasani, P. (2022, September 19). Breast Cancer. Medscape. Retrieved November 26,
2022 from https://emedicine.medscape.com/article/1947145-overview
Cleveland Clinic. (2022, January 21). Breast Cancer. Retrieved November 26, 2022 from
https://my.clevelandclinic.org/health/diseases/3986-breast-cancer
Columbia University Irving Medical Center. (2022, December 2). Breast Implants after
Mastectomy Associated With Very Low Risk of Lymphoma. Jama Network Open
Retrieved January 2, 2023 from https://medicalxpress.com/news/2022-12-breast-
implants-mastectomy-lymphoma.html

Franceschini, G., et al. (2022, June 24). Editorial: Update of Current Evidences In Breast
Cancer Surgery. Open Access. Retrieved January 2, 2023 from
https://www.frontiersin.org/articles/10.3389/fonc.2022.928467/full
Selchick, F. (2022, February 16). A Comprehensive Guide to Breast Cancer. Healthline.
Retrieved November 26, 2022 from https://www.healthline.com/health/breast-
cancer#awareness
Thomas, T. (2021, October 25). What to know about breast cancer. Medical News Today.
Retrieved November 26, 2022 from
https://www.medicalnewstoday.com/articles/37136

BOOKS
Brunner, L. S., Suddarth, D. S., Smeltzer, S. C. O., & Bare, B. G. (2004). Brunner &
Suddarth's textbook of medical-surgical nursing (10th ed.). Philadelphia: Lippincott
Williams & Wilkins.
Doenges, M., Moorhouse, M.F., & Murr, A. (2019). Nursing care plans: guidelines for
individualizing client care across the lifespan, 10th edition. F.A. Davis Company.
Jones & Bartlett. (2015). 2015 Nurse’s Drug Handbook; 14th edition. Jones and Bartlett
Learning. Massachusetts.
Schull,P.D. (2013). Nurse’s Drug Handbook; 7th edition. Mc-Graw-Hill Education, LLC.