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LIPA CITY COLLEGES LIPA CITY, BATANGAS

BREAST CANCER A case study

In partial fulfillment of the requirements for the Degree of Bachelor of Science in Nursing

Submitted to: Sir Jose Rene Siansioco

Submiited by:
Aldueza, Julie Ann Bisco, Jonathan Cueto, Glenda Dimaunahan, Dennis Encallado, Nixon Hernandez, Maria Martha Laygo, Jovan Luna, Anne Marie Marbella, Roselle Saludo, Shangrila

I.

INTRODUCTION Breast cancer is growth of malignant cells at breast. It starts when the DNA of a cell is altered due to carcinomas. There is excessive or abnormal mitosis of cells in the breast. The cancer cells may travel through bloodstream and/or lymphatic system and may spread to the other organs, which are called metastasis.

Hormone estrogen plays an important role in the development of breast cancer. Factors that affect its development is early menstruation and late menopause, obesity after menopause and having no child and lastly late pregnancy. Increase in estrogen level may increase risk of breast cancer. Another factor is family history of cancer, About 5 per cent of breast cancers are linked to family history. The risk for a woman whose mother or sister had breast cancer is at least double that of someone with no family history. If her relatives were under 40 when diagnosed, her risk is even higher.

Signs and symptoms of breast cancer includes unusual lump or increase in breast size, drawing back of nipple, swelling of the upper arm, or in the armpit, or just above the breast and/or pain. According to World Health Organization every year 1.2 million are diagnosed with breast cancer worldwide. Despite an increasing incidence rate, deaths from breast cancer are starting to decline or level off in many European countries including Britain, where deaths from the disease have fallen by 10 per cent in the past five years. Incidence and mortality vary considerably between countries. Of age-standardized rates, cases per 100,000 women, incidence and mortality are in Australia, 59.6 and 21.41; in England and Wales, 56.1 and 30.27. A study carried out in Miyagi, Japan,

produced comparatively low figures of 27.8 and 6.11. As with most cancers, the earlier breast cancer is diagnosed, the greater the chance of a cure. Stage 1 is a cancer in a very early stage; stage 4 is one which has already spread to many organs. In Britain the survival rates by stage of cancer development are: 84 per cent (stage 1), 71 per cent (stage 2), 48 per cent (stage 3), 18 per cent (stage 4). For early breast cancer, mastectomy is recommended and followed with radiotherapy while advanced breast cancer is aimed by giving the patient a manageable quality of life with the disease kept under control, rather than a cure. Conventional treatments include drugs which cut estrogen levels, and various chemotherapy combinations. Some women have bone metastases that cause pain and fractures.

II.

PATIENT S PROFILE Name: Patient X Age: 67 Address: Lapu-lapu St. West Rembo, Makati City Sex: Female Nationality: Filipino Religion: Roman Catholic Birthday: 08/19/1944 Date of Admission: January 18, 2011 Ward: Oncology Ward Attending Physician: Dr. Y Admitting Diagnosis: Breast Cancer

III.

PHYSICAL ASSESSMENT Methods used/ procedure  Inspection Normal Findings Actual Findings Remarks

Area assessed Skin y

Color

 Varies from light  Varies from light to to deep brown, deep brown, from ruddy from ruddy pink pink to light pink, from to light pink, from yellow overtones to yellow overtones olive to olive  Uniform within normal range(36.5-37.5)  Uniform within normal range(T: 37)

Normal

Temperature

 Palpation

Normal

Moisture

 Inspection; palpation

 Moisture in the  Moisture in the skin skin folds and the folds and the axilla axilla (varies with (varies with environmental environmental temperature and temperature and humidity, body humidity, body temperature and temperature and activity) activity)  Springs back to

Normal

Turgor

 Inspection; palpation y y Tenderness  Palpation Lesions  Inspection

 Springs back to normal when pinched  Skin surfaces are non-tender  Absence of lesions

normal when pinched within 4 seconds  Skin surfaces are non-tender  Presence of lesions on the Right breast  Absence of edema

Normal

Normal Abnormal (there is a mass erupted on the breast) Normal

Edema  Inspection
 Absence of edema

Hair y

Distribution

 Inspection

Texture

 Palpation

Color

 Inspection

Seborrhea

 Inspection

 Evenly distributed over the scalp  Fine or thick hair; straight,curly or kinky; silky,resilient hair  Black color or gray color,considering the age  Absence of seborrhea

 Alopecia (hair loss)

Due to chemotherapy Due to aging

 Thin hair

 White color of hair

Due to aging

 Absence of seborrhea

Normal

Nails
y y Appearance Color of nailbed Shape Texture Capllary refill Time Shape and size Facial features  Inspection  Inspection  Inspection  Inspection  Palpation  Clean nails  Pink  Convex to curvature  Smooth  Return within 2-3 seconds

 Uncut nails and slightly dirty  Pink  Convex to curvature  Smooth  Return within 3seconds

Due to poor hygiene Normal Normal Normal normal

y y y

Head
y y  Inspection  Inspection  Rounded,smooth  Rounded,smooth skull skull contour contour  Symmetric or  Symmetric or slightly slightly asymmetric facial asymmetric facial features features  Symmetric facial  Symmetric facial movements movements

Normal Normal

Symmetry of facial features

 Inspection

Normal

Ears
Auricle y Position Texture  Inspection  Inspection  At the level of the  At the level of the external cantus external cantus of the of the eyes eyes  Smooth without  Smooth without Lesion Lesion

Normal

Normal

External Auditory canal y Discharges y Color of canal walls

 Inspection  Inspection

 None  Pink

 None  Pink

Normal Normal Normal Normal Normal

Nose
y y y y Color Sinuses Nares Lesion/ Tenderness

 Inspection  Inspection  Inspection  Palpation

 Same color with the face  Not inflamed  No obstruction; oval and symmetric  Not tender; absence of lesion

 Same color with the face  Not inflamed  No obstruction; oval and symmetric  Not tender; absence of lesion

Normal

Lips
y y y Symmetry Color Texture

 Inspection  Inspection  Palpation  Inspection

 Symmetrical  Pinkish  Smooth  Free from decays, white, smooth and shiny  Center  Pink
 Centrally located on the shoulder  Able to flex and extend head without pain and resistance  Not palpable

 Symmetrical  Pinkish  Smooth With tooth decay; without teeth on the upper part

Normal Normal normal Due to aging and present condition Normal Normal

Teeth

Tongue
y y Position Color

 Inspection  Inspection  Inspection  Inspection

 Center  Pink
 Centrally located on the shoulder  Able to flex and extend head without pain and resistance  With palpable lymph nodes

Neck
y y Position Movement

Normal Normal

Lymph nodes

 Palpation

Due to present condition

Thorax and Lungs


Anterior thorax and lungs y Breathing patterns y y Symmetry Lung breath sounds

 Inspection

 Quiet,Rhythmic and Effortless Respiration

 Quiet,Rhythmic and Effortless Respiration  Symmetrical  No adventitious sound

Normal

 Inspection  Symmetrical  Auscultation  No adventitious


sound

Normal Normal

Breast y Symmetry

 Inspection

 Symmetrical

 Right breast enlarged  with presence of mass  Regular rate  No murmur  Flat rounded

due to erupted mass Due to cancerous cell Normal Normal Normal

Lesions

 Inspection

 Without lesions

Heart y Rate y Rhythm

 Auscultation  Auscultation  Inspection

 Regular rate(60100)  no murmur

Abdomen y contour Upper and Lower Extremities


y y y y y Size Symmetry Distribution of hair Skin color Lesions

 Flat rounded

    

Inspection Inspection Inspection Inspection Inspection

   

Equal size Symmetrical Evenly distributed Light to deep brown  No lesions, deformities or inflammation

   

Equal size Symmetrical Evenly distributed Light to deep brown

Normal Normal Normal Normal Normal

 No lesions, deformities or inflammation

Musculoskeletal y Joints

 Inspection

 No swelling on the skin and tissues over the joints  Full ROM against gravity,full resistance, 5/5

No swelling on the skin and tissues  Full ROM against gravity,full resistance, 5/5

Normal

ROM

 Inspection

Normal

IV.

HEALTH HISTORY  History of Present Illness 10 years ago PTA, according to the patient palpated a mass on her right breast but she did not consulted any medical help until the mass erupted last 2009. She had radiotherapy and first cycle of Chemotherapy last Dec. 28, 2010. On January 18, 2011 she was admitted for her second cycle of chemotherapy under the service of Dr. Y.  Past medical history The patient states that she had Diabetes Mellitus and take Metformin as maintenance drug.  Family History The patient states that they have history of Cancer on her maternal side and Diabetes Mellitus on both sides of their family.

V.

ANATOMY AND PHYSIOLOGY Lymphatic System: Lymphatic Is a circulatory vessels or ducts which the fluid bathing the tissue cells or vertebrates is collected and carried to join the bloodstream. It transports digested fat from intestine to the bloodstream. This system detoxifies the bloodstream and resists spread of disease in the body. LYMPHATIC CAPILLARIES- this lymph capillary function as an ordinary capillaries and same to its structure. lymphatic capillaries are more permeable than ordinary capillaries and allow passage of larger particles than would ordinarily pass through capillary walls; large-molecule proteins, produced as a result of tissue breakdown, pass into the lymphatics for transport away from the tissues. LYMPH NODES-Along the course of the lymphatic vessels are situated the lymph nodes, more commonly called the lymph glands. These nodes are bean-shaped organs containing large numbers of leucocytes, embedded in a network of connective tissue. All the lymph being returned along the lymphatics to the bloodstream must pass through several of these nodes, which filter out infectious and toxic material and destroy it. The nodes serve as a centre for the production of phagocytes, which engulf bacteria and poisonous substances During the course of any infection, the nodes become enlarged because of the large number of phagocytes being produced; these nodes are often painful and inflamed. The swollen glands most often observed are located on the neck, in the armpit, and in the groin. Certain malignant tumors tend to travel along the lymphatics; surgical removal of all nodes that are suspected of being involved in the spread of such malignancies is an accepted therapeutic procedure. OTHER ORGAN SPLEEN-Spleen, flattened, oblong, glandlike organ, situated in the upper left abdominal cavity, in contact with the pancreas, the diaphragm, and the left kidney, and supported by bands of fibres that are attached to the peritoneum (the membrane lining the abdominal cavity). The spleen varies in size but, in adult humans, is about 13 cm (5 in) long, up to 10 cm (4 in) wide and 3.8 cm (1.5 in) thick, and weighs about 200 g (7 oz).The spleen is no longer

regarded as an endocrine gland because it apparently produces no secretions, although in disease it may elaborate a hormone that affects the production of red blood cells in the bone marrow. In the unborn child, the organ functions primarily to produce red blood cells. This activity normally ceases after birth but may be resumed later if diseases slow down this function in the bone marrow. Some people are born without spleens it also removes such waste materials as bile pigments for excretion as bile by the liver. The spleen produces antibodies against various disease organisms and manufactures a variety of blood cells. In some mammals (but not in humans) it stores red blood cells and feeds them into the circulation to maintain the volume of blood in cases of hemorrhage. LYMPH-Lymph, common name for the fluid carried in the lymphatic system. Lymph is diluted blood plasma containing large numbers of white blood cells, especially lymphocytes, and occasionally a few red blood cells. Because of the number of living cells it contains, lymph is classified as a fluid tissue.

VI.

PATHOPHYSIOLOGY

VII.

LABORATORY RESULTS MARCH 28.2011

Examinations WBC count SEGMENTER LYMPHOCYTE BOSONOPHIL HEMOGLOBIN HEMATOCRIT PLETELET COUNT

HEMATOLOGY Result 7.75 0.81 0.17 0.02 98 0.30 366

Normal range 5-10 x 10 9/L 0.60-0.70 0.20-0.40 0.01-0.05 M-140-180 F-120-160 M-0.40-0.54 F-0.37-0.47 A 150-450X10 9/L NB 1595X10 9/L

MARCH 28,2011 BIOCHEMISTRY Results 3.8 33 130 95 3.5

Examinations UREA CREATININE SODIUM CHLORIDE POTASSIUM

Normal Values 1.9-9.2 53-133 135-156 95-105 3.6-5.5

VIII.

COURSE IN THE WARD DAY 1 On march 29, 2011, patient was lying on bed with ongoing IV fluid of D5 NM 1L regulated at 100 cc/hr at 550 level at 6:00 in the morning. At 8:00 am, Omeprazole 20 mg/cap, Ascorbic acid 500mg tab and Metformin 500 mg/tab was given. Patient was seen and examined by Dr. Ramos at 9:00 am she ordered to consume IV fluid and continue present management. At 11:00 in the morning CBG was monitored and her latest CBG was 168mg/dl. IV fluid was consumed at 1:00 pm and followed up by same IV fluid regulated at 100 cc/hr and metformin 500 mg was given. DAY 2 On march 30,2011, the patient was sitting beside her bed with IV fluid of D5 NM 1L on KVO. Morning care done by student nurses. At 8:00 am, Omeprazole 20 mg/cap, Ascorbic acid 500mg tab and Metformin 500 mg/tab was given. At 9:00 am Dr. Ramos ordered to consume IV fluid. Consumed IV Fluid at 10 am and was discontinued as ordered by attending physician. Vital signs were taken and recorded and no irregularities noted. At 11:00 am CBG was monitored, the result was 59mg/dl. Metformin 500 mg was given at 1:00 pm.

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