Introduction

Breast cancer continues to be a global public health issue, and it is now the most frequent malignancy on
the planet. Breast cancer awareness, public awareness, and advancements in breast imaging have all helped to
improve breast cancer detection and screening. Breast cancer is a life-threatening disease that affects women and is
the main cause of death among them (Akram, Iqbal, Daniyal, & Khan, 2017).

Breast cancer is a disorder in which the cells of the breast get uncontrollably large. The type of breast
cancer is determined by which cells in the breast become cancerous. (“Centers for Disease Control and Prevention”,
2021). According to Singh & Chakrabarti (2019), breast cancer is a complicated disease that is divided into
subgroups depending on the tumor's morphological, immunohistochemical, and clinical characteristics, and it could
affect both men and women but more particularly to women because of having more complicated hormonal
relationships and imbalances.

As stated by Akram et.al (2017), there are two main types of breast cancer: Non-invasive, and Invasive
cancers.

Non-invasive cancers are cancers that have not spread beyond the lobule or ducts in which they are found.
Ductal carcinoma in situ is an example of a type of non-invasive breast cancer. Ductal carcinoma in situ develops
when abnormal cells form within the milk ducts but do not spread to nearby tissue or to the outside.

Invasive cancers are when abnormal cells from within the lobules or milk ducts split out into close
proximity of breast tissue. Through the immune system or the systemic circulation, cancer cells can spread from the
breast to other regions of the body. They may move early in the formation of the tumor when it is little or later when
it is large. Invasive breast cancer is the most common type of general carcinoma in women.

Changes in the appearance or feel of the breast, nipple and nipple discharge are common symptoms of
breast cancer. Regular breast examinations can help detect these symptoms early and prevent disease progression.
Other symptoms include redness or scariness of the nipple or breast skin, or a discharge (Ikhuoria, E., & Bach, C.,
2018).

There are many diagnostic tests for breast cancer such as digital mammography, magnetic resonance
imaging, and molecular breast imaging, but the best and the only definitive method for diagnosing breast cancer is
through a breast biopsy (Nounou, M., ElAmrawy, F., Ahmed, N., Abdelraouf, K., Goda, S., & Syed-Sha-Qhattal,

1
2015). Clinical breast examination, breast imaging, and biopsy are all performed at the same time to improve
diagnosis accuracy and remove as many false negative results as possible (triple test).

According to Ikhuoria, & Bach (2018), there are four main treatment and therapies for breast cancer which
are: Endocrine therapy, H90 inhibitor, Chemotherapy, and Surgery, but the most commonly done therapies are
chemotherapy and surgery, in which it is the best approach to control, prevent, and suppress the breast cancer.

Chemotherapy is a common treatment for breast cancer that has considerably increased patient survival
rates. It is the use of a combination of drugs that suppress and kills the cancer cells. Patients may experience
behavioral challenges when controlling their symptoms as a result of the various etiologies of chemotherapy side
effects. Common side effects are constipation, diarrhea, and stomach discomfort.

Surgery is either mastectomy or lumpectomy depending on the size, location, and preference of the patient.
Breast conserving surgery is a popular therapeutic option for localized breast cancer. The procedure is preceded with
neoadjuvant therapy, which is used to reduce the size of the tumor. Adjuvant treatment is frequently used after
surgery to guarantee full healing and reduce the chance of metastases. Radiation can eliminate cancer cells that
aren't visible during surgery, lowering the risk of a local recurrence (Nounou et.al, 2015).

2
ASSESSMENT

A. Health History

Vital Information

Name: Rebecca Caro

Age: 63

Sex: Female

Civil Status: Single

Chief Complaint: Right Breast Mass

Date and Time of Admission: February 21, 2022

History of Present illness

2 weeks prior to admission, patient had noted breast mass on the right. Consult done are week PTA & ultrasound
done then biopsy taken. Results indicated malignancy, thus advised surgical intervention, thus this admission.

Past Medical History

The patient has past medical history of Myoma, and hypertension

Family History

The patient’s mother died from cancer; she also had two first degree cousins, one from her father’s side and also one
from her mother’s side that had breast cancer. She had a brother who also died from cancer.

B. Laboratory & Diagnostic tests

CLINICAL CHEMISTRY

TEST RESULTS NORMAL VALUES INTERPRETATION SIGNIFICANCE

Creatinine 0.60 0.6-1.72mg/dL Normal

TEST RESULTS NORMAL VALUES INTERPRETATION SIGNIFICANCE

Na 138.1 135-155 mmol/L Normal
K+ 3.23 3.6-5.5 mmol/L Decreased Hypokalemia
Ca+ 1.22 1.13-1.32 mmol/L Normal
FECALYSIS

TEST RESULTS SIGNIFICANCE

Stool Color Brown
Consistency Watery Diarrhea

3
Pus 0
RBC 0
Others No parasite

4
C. ASSESSMENT DIAGRAM

Psychological
Developmental

Patient is mentally stable and is Generativity vs Stagnation Socio-Cultural

ready to adjust with the changes Patient goes to hospital if feeling unwell,
Patient enjoys developing her relationships with her
especially if there are lumps around the
family members.
body

Neurologic-Sensory Patient Information Respiratory

Name: Caro, Rebecca
Subjective: Subjective:
Age: 63
Objective: Gender: Female
Lab & Dx Test: Civil Status: Single Objective:
Medications: Post-op medicine: Ketorolac 30mg IV 6 hours x4 Chief Complaint Right Breast Mass
dosage, Nalbuphine 5mg IV q hours for breakthrough severe pain Final diagnosis: Right Breast Cancer
Nursing Diagnosis:
Lab & Dx Test:

Medications

Nursing Diagnosis:
Musculo-Skeletal
Subjective: Hematology Immunologic
Objective: Subjective:
Lab & Dx Test:
Subjective:
: Objective: Pale nailbeds

Objective
Lab & Dx Test:

Lab & Dx Test:

Medications:
Medications: Prophylaxis- silgram
Nursing Diagnosis: 1.5 gm IVTT ANST on call to OR

Nursing Diagnosis:

5
Reproductive/Sexuality
Metabolism-Endocrine
Subjective: “painless, pulsating feeling on the
Subjective: Urinary
lump”
Objective: Subjective:
Lab & Dx Test: Objective:
Objective: Right Breast mass, immovable, about
Medications: Lab & Dx Test:
2 inches in length and 2 inches in width
Nursing Diagnosis: Medications:
Nursing Diagnosis:
Lab & Dx Test: Medications: Noncompliance

Integumentary
Subjective:
Objective: Post op: Scanty red drainage, no pain and
numb feeling on the incision site,
Lab & Dx Test:
Medications: Digestive Cardiovascular
Nursing Diagnosis:
Subjective: Subjective:
Objective: 130/90 to
Objective: 140/100 mmhg
Lab & Dx Test:
Lab & Dx Test: Fecalysis: Watery; Electrolyte
test: K=3.23 mmol/L Ultrasound:
Medications: Kenzar 50/mg tab 1
Medications: Racecadotril 1 cap TID, Kalgen 1 tab bid po
LEGEND:
tab TID, Nursing Diagnosis:
BLACK – patient based Nursing Diagnosis:
RED – book based

6
Review of Anatomy and Physiology

BREAST
Male and female breasts mature comparably until puberty, when estrogen and other hormones initiate
breast development in females. This development usually occurs from 10 to 16 years of age, although the range can
vary from 9 to 18 years. Stages of breast development are described as Tanner stages 1 through 5: • Stage 1
describes a prepubertal breast. Stage 2 is breast budding, the first sign of puberty in a female. • Stage 3 involves
further enlargement of breast tissue and the areola (a darker tissue ring around the nipple). Stage 4 occurs when the
nipple and areola form a secondary mound on top of the breast tissue. • Stage 5 is the continued development of a
larger breast with a single contour. The breasts are located between the second and sixth ribs over the pectoralis
muscle from the sternum to the midaxillary line. An area of breast tissue, called the tail of Spence, extends into the
axilla. Fascial bands, called Cooper ligaments, support the breast on the chest wall. The inframammary fold (or
crease) is a ridge of fat at the bottom of the breast. Each breast contains 12 to 20 cone-shaped lobes, which are made
up of glandular elements (lobules and ducts) and separated by fat and fibrous tissue that binds the lobes together.
Milk is produced in the lobules and then carried through the ducts to the nipple.

SKIN
The skin is composed of three layers: epidermis, dermis, and subcutaneous tissue (see Fig. 60-1). The
epidermis is an outermost layer of stratified epithelial cells, composed predominantly of keratinocytes. It ranges in
thickness from about 0.05 mm on the eyelids to about 1.5 mm on the palms of the hands and soles of the feet. Four
distinct layers compose the epidermis; from innermost to outermost, they are the stratum germinativum, stratum
granulosum, stratum lucidum, and stratum corneum. Each layer becomes more differentiated file, mature and with
more specific functions) as it rises from the basal stratum germinativum layer to the outermost stratum corneum
layer.
Epidermis
The epidermis, which is contiguous with the mucous mem. branes and the lining of the ear canals, consists of
live, continuously dividing cells called keratinocytes, which differentiate and randomly migrate upward. These cells
synthesize keratin; eventually they become metabolically inactive and form a thick and protective outer layer. This
external layer, called the stratum corneum, is almost completely replaced every 3 to 4 weeks. The dead cells contain
large amounts of keratin, an insoluble, fibrous protein that forms the outer barrier of the skin and has the capacity to
repel pathogens and prevent excessive Aid loss from the body. Keratin is the principal hardening ingredient of the
hair and nails. Melanocytes are the special cells of the epidermis that are primarily involved in producing the
pigment melanin, which colors the skin and hair. An individual's normal skin color is determined by the amount of
melanin produced. Most of the skin of people who are dark skinned and the darker areas of the skin on people who
are light skinned (e.g., the nipple) contain larger amounts of melanin and are not related to numbers of melanocytes.
Normal skin color depends on race and varies from pale, almost ivory, to deep brown, almost pure black. Systemic
disease affects skin color as well. For example, the skin in those who are light skinned appears bluish when there is
insufficient oxygenation of the blood, yellow green in People with jaundice, or red or flushed when there is

7
inflammation or fever. Production of melanin is influenced by a number of factors including a hormone secreted
from the hypothalamus called melanocyte stimulating hormone. It is believed that melanin production responds in a
protective manner with ultraviolet light in sunlight. Two other types of cells are common to the epidermis: Merkel
and Langerhans cells. Merkel cells are not fully under- stood but may have a role as receptors that transmit stimuli to
the axon through a chemical synapse. Langerhans cells are believed to play a significant role in cutaneous immune
system reactions. These accessory cells of the afferent immune system process invading antigens and transport the
antigens to the lymph system to activate the T lymphocytes. The characteristics of the epidermis vary in different
areas of the body. It is thickest over the palms of the hands and soles of the feet and contains increased amounts of
keratin. The thickness of the epidermis can increase with friction and pressure and can result in calluses forming on
the hands or corns forming on the feet. The junction of the epidermis and dermis is an area of undulations and
furrows called rete ridges on the epidermal side and dermal papillae on the dermal side. This junction is where
anchors are found that hold together the epidermis and dermis and permits the free exchange of essential nutrients
between the two layers. This interlocking between the dermis and epidermis produces ripples on the surface of the
skin. On the fingertips, these ripples are called fingerprints. They are a person's most individual physical
characteristic, and they rarely change over time (Wilhelmi & Molnar, 2014).
Dermis
The dermis makes up the largest portion of the skin, the connective tissue between the epidermis and
subcutaneous tissue. It provides strength and structure in the form of collagen and elastic fibers. It is composed of
two layers: papillary and reticular. Collagen fibers are loosely organized in the papillary dermis and are more tightly
packed in the reticular dermis. The dermis also contains blood and lymph vessels, nerves, sweat and sebaceous
glands, and hair roots.
Subcutaneous Tissue
The subcutaneous tissue, or hypodermis, is the innermost layer of the skin. It is primarily adipose
and connective tis- sue, which provides a cushion between the skin layers and the muscles and bones. This layer also
protects the nerve and vascular structures that transect the layers. It promotes skin mobility, molds body contours,
and insulates the body. The subcutaneous tissues and the amount of fat deposited are important factors in body
temperature regulation.

8
Concept Map

63 YEARS OLD FEMALE HIGH MEAT DIET GENETICS

PROLONGED PRODUCTION OR EXPOSURE TO INCREASED

ESTROGEN AND PROGESTERONE WHICH ARE CARCINOGENS IN THE  BRCA1 AND BRCA2
POTENT PROMOTERS BODY MUTATIONS

 CHANCES FOR ONCOGENES AND TURNING OFF OF

Silgram 1.5 gm IVTT ANST
SUPPRESOR GENES
on call to OR
Omeprazole 40mg IV on call
to OR
Metoclopramide10mg/amp
IV on call to OR
MODIFIED RADICAL Ketorolac 30mg IV 6 hours

BREAST CANCER MASTECTOMY

x4 dosage
Nalbuphine 5mg IV q hours
for breakthrough severe pain

LEGEND:

RISK FACTOR
DIARRHEA
PATHOPHYSIOLOGY
BREAST MASS FINAL DX
CLINICAL MANIFESTATION
K=3.23mmol/L Racecadotril 1 cap TID
SURGICAL INTERVENTION
Kaligen 1 tab TID
S/S
9 MEDICATION
LABORATORY RESULTS
ANALYSIS OF RISK FACTORS

Age and Female Gender

Being female and getting older is one of the main risk factors of breast cancer because the breast of the
females is exposed constantly to the estrogen and progesterone hormones which has growth-promoting effects that
could lead to possible genetic errors causing cancer. Risk of breast cancer increases with increasing age (Thakur, P.,
Seam, K,. Gupta, MK., Gupta, M., Sharma, M., & Fotedar, V., 2020). Factors such as early menarche and late
menopause also contributes to this field of risk factors as the woman will be continually exposed to the growth-
promoting effects in a longer period of time.

High Red Meat and Fatty food Intake

Intake of high red meat have a correlation of heme iron consumption with the creation of unstable N-
nitroso compounds that could in return cause cancer. There is increasing evidence that dairy protein and milk intake
increases circulating IGF-I level, which is linked to breast cancer (Ikhuoria, E., & Bach, C., 2018). Increased
estrogen production in adipose tissue induces inflammation and changes in various physiologic processes, leading to
a higher risk of breast cancer, according to the mechanism hypothesized for the influence of dietary fat on breast
cancer.

Genetics

Family history is a well-known risk factor for breast cancer, and it varies depending on the number of
cases, the age of the breast cancer, and the degree of relatives involved in the cases to be compared to women who
do not have any first-degree relatives who have breast cancer (Ikhuoria, E., & Bach, C., 2018). BRCA1/2, the
BRCA1 gene product involved with DNA repair, is a nuclear phosphoprotein that participates in the DNA damage
response and cell cycle. Women having BRCA1 mutations have a lifetime risk of breast cancer of up to 80%, with a
higher frequency of cancer risk at younger ages. There are several high-risk breast cancer susceptibility genes
known, including BRCA1, BRCA2, PALB2, TP53, CDH1, and PTEN.

10
Theoretical Analysis

A. Textbook-based Nursing Care

Health promotion about risk factors

A person can reduce her risk factors by maintaining a healthy weight, exercising regularly, limiting
alcohol, eating nutritious food, and never smoking (or quitting if she does smoke). It is important for you to
encourage people to adhere to the breast cancer screening. If a person is at high risk, she needs to develop an
individualized plan with the health care provider. Early detection can decrease the morbidity and mortality
associated with breast cancer. Along with these lifestyle choices, there are other risk reduction options for women at
high risk. Genetic testing for BRCA gene mutations is available. People with a strong family history of breast cancer
should talk with their health care provider about the possibility of genetic testing. Routine screening for genetic
abnormalities in women without evidence of a strong family history of breast cancer is not warranted. In women
with an abnormal BRCA1 or BRCA2 gene, prophylactic oophorectomy may reduce their risk of developing breast
cancer. In deciding whether and when to undergo this surgical procedure, women should receive counseling about
the risks and benefits of prophylactic oophorectomy, including fertility issues.

Emotional and Psychologic Care

Throughout history, the female breast has been regarded as a symbol of beauty, femininity, sexuality, and
motherhood. The potential loss of a breast, or part of a breast, may be devastating for many women because of the
significant psychologic, social, sexual, and body image implications associated with it. From the time of diagnosis
through treatment, survivorship, or metastatic disease, the woman may exhibit signs of distress or tension (e.g.,
tachycardia, increased muscle tension, sleep disturbances, restlessness, changes in appetite or mood). Assess the
woman’s body language and affect during periods of high stress and indecision so that appropriate interventions,
including referral to a mental health provider, can be initiated.
Remain sensitive to the complex psychologic impact that a diagnosis of cancer and subsequent breast
surgery can have on a woman and her family. A relationship in which the woman can express her feelings is
therapeutic. With an accepting attitude and the offer of resources, you can help with the feelings of fear, anger,
anxiety, and depression. Help to meet the woman’s psychologic needs by
• Providing a safe environment for the expression of the full range of feelings.
• Helping her identify sources of support and strength, such as her partner, family, and spiritual or religious
practices.
• Encouraging her to identify and learn individual coping strengths.
• Promoting communication between the patient and her family or friends.
• Providing accurate and complete answers to questions about her disease; treatment options; and reproductive,
fertility, or lactation issues (if appropriate).
• Making resources available for mental health counseling.
• Offering information about local and national community resources. Referring her to peer support resources, such
as Reach to Recovery or local breast cancer organizations, is invaluable. The Reach to Recovery program of the
American Cancer Society is a rehabilitation program to help meet the psychologic, physical, and cosmetic needs of
women who have had breast surgery. The American Cancer Society and the National Cancer Institute can provide
excellent materials to assist you in meeting the special needs of women with breast cancer.

Ambulatory and home care

Explain the specific follow-up plan to the patient and emphasize the importance of ongoing monitoring and
self-care. Immediately after surgery, advise the patient to report to the health care provider symptoms such as fever,
inflammation at the surgical site, erythema, postoperative constipation, and unusual swelling. Other changes to
report are new back pain, weakness, shortness of breath, and change in mental status, including confusion. For
women who have had a mastectomy without breast reconstruction, a variety of products are available. These include
garments such as camisoles with soft breast prosthetic inserts or a fitted prosthesis with bra. Should the woman
choose a breast prosthesis, a certified fitter can help her select a comfortable, more permanent weighted prosthesis

11
and bra, generally at 4 to 8 weeks postoperatively. Your role is to present the choices and resources without
judgment. How the loss of part or all of the breast and cancer affect the woman’s sexual identity, body image, and
relationships can vary. If you are comfortable, initiate a discussion of sexuality by inviting questions about
relationships or intimacy concerns. Often the husband, sexual partner, or family members need help dealing with
their emotional reactions to the diagnosis and surgery before they can provide effective support for the patient.
There are no physical reasons why a mastectomy would prevent sexual satisfaction. The woman taking hormone
therapy may have a decreased sexual drive or vaginal dryness. She may need to use lubrication to prevent
discomfort during intercourse. Concerns about sexuality are not well addressed by many health care providers. If
difficulty in adjustment or other problems develop, counseling may be necessary to deal with the emotional
component of a mastectomy and the diagnosis of cancer. Depression and anxiety may occur with the continued
stress and uncertainty of a cancer diagnosis. A woman’s self-esteem and identity may also be threatened. The
support of family and friends and participation in a cancer support group are important aspects of care that may
improve the patient’s quality of life (Lewis, S., Dirksen, S., Heitkemper, M., & Bucher, L., 2014).
.

B. Textbook-based Medical-Surgical Management

Brachytherapy
Brachytherapy (internal radiation) is used for partial-breast radiation as an alternative to traditional external
radiation treatment for early-stage breast cancer. Radiation is delivered directly into the cavity left after a tumor is
surgically removed by a lumpectomy. This approach is a minimally invasive way to deliver radiation. Because the
radiation is concentrated and focused on the area with the highest risk for tumor recurrence, internal radiation only
requires 5 days. Traditional external radiation treatments can take 5 to 7 weeks. Internal radiation therapy is
primarily delivered using a multicatheter method or balloon-catheter system.

Palliative Radiation Therapy

In addition to reducing the primary tumor mass with a resultant decrease in pain, radiation therapy is also
used to treat symptomatic metastatic lesions in such sites as bone, soft tissue organs, brain, and chest. Radiation
therapy often relieves pain and is successful in controlling recurrent or metastatic disease.

Chemotherapy
Chemotherapy refers to the use of cytotoxic drugs to destroy cancer cells. Many breast cancers are
responsive to chemotherapy. In some patients, chemotherapy is given preoperatively. Preoperative (neoadjuvant)
chemotherapy may decrease the size of the primary tumor, with the goal of less extensive surgery. The use of
combinations of drugs is usually superior to the use of a single drug. The benefit of combination treatment results
from the use of drugs that have different mechanisms of action and work at different parts of the cell cycle. The
more common combination-therapy protocols are (1) CMF— cyclophosphamide (Cytoxan), methotrexate, and 5-
fluorouracil (5-FU); (2) AC—doxorubicin (Adriamycin) and cyclophosphamide, with or without the addition of a
taxane such as paclitaxel (Taxol) or docetaxel (Taxotere); or (3) CEF or CAF— cyclophosphamide, epirubicin
(Ellence) or doxorubicin (Adriamycin), and 5-FU.

Hormone Therapy
Estrogen can promote the growth of breast cancer cells if the cells are estrogen receptor positive. Hormone
therapy can block the effect and source of estrogen, thus promoting tumor regression. Hormone therapy may be used
as an adjuvant to primary treatment or in patients with recurrent or metastatic cancer. Both estrogen and
progesterone receptor status assays have been developed to identify women whose breast cancers are likely to
respond to hormone therapy. These assays reliably predict whether hormone therapy is a treatment option. Chances
of tumor regression are significantly greater in women whose tumors contain estrogen and progesterone receptors.
Hormone therapy can (1) block estrogen receptors or (2) suppress estrogen synthesis by inhibiting aromatase, an
enzyme needed for estrogen synthesis. Antiestrogens include tamoxifen, toremifene (Fareston), and fulvestrant
(Faslodex).
Estrogen Receptor Blockers-Tamoxifen has been the hormonal agent of choice in estrogen receptor–positive
women with all stages of breast cancer over the past 30 years. It is commonly used in early-stage or advanced breast
cancer and to treat recurrent disease. Tamoxifen may also be used in high-risk premenopausal and postmenopausal
women to prevent breast cancer. Side effects of tamoxifen may include hot flashes, mood swings, vaginal discharge
and dryness, and other effects commonly associated with decreased estrogen. It also increases the risk of blood clots,

12
cataracts, stroke, and endometrial cancer in postmenopausal women. Treatment with tamoxifen is generally
prescribed for 5 years.
Aromatase Inhibitors- Aromatase inhibitor drugs interfere with the enzyme aromatase, which is needed for the
synthesis of estrogen. These drugs, including anastrozole, letrozole (Femara), and exemestane (Aromasin), are used
in the treatment of breast cancer in postmenopausal women. Aromatase inhibitors do not block the production of
estrogen by the ovaries. Thus, they are of little benefit and may be harmful in premenopausal women.
Estrogen Receptor Modulator and Others- Raloxifene (Evista) is a selective estrogen receptor modulator that
produces both estrogen-agonistic effects on bone and estrogen-antagonistic effects on breast tissue.

Biologic and Targeted Therapy

Trastuzumab (Herceptin) is a monoclonal antibody to HER-2. After the antibody attaches to the antigen, it
is taken into the cells and eventually kills them. It can be used alone or in combination with chemotherapy agents
such as docetaxel or paclitaxel to treat patients whose tumors overexpress HER-2. Additional genetic testing (e.g.,
SPoT-Light test) may offer information on which patients are good candidates for treatment with trastuzumab.

Follow-up and Survivorship Care

After treatment for breast cancer, the patient will have ongoing survivorship care. Recommended follow-up
examinations generally occur every 3 to 6 months for the first 5 years, and then annually thereafter. Survivorship
care plans summarize a patient’s care and care plan for ongoing surveillance.30 In addition, advise women to
perform monthly BSE and self–chest wall examination, and report any changes to their health care provider. Local
recurrence of breast cancer is usually at the surgical site. The woman should have appropriate breast imaging done at
regular intervals (usually 6 months to 1 year) as determined by her risk of recurrence and breast cancer history
(Lewis, S., Dirksen, S., Heitkemper, M., & Bucher, L., 2014).

13
NPR

NURSING DIAGNOSIS: Impaired skin integrity r/t mechanical incision secondary to Modified Radical Mastectomy
NANDA DEFINITION: alteration in the epidermis and/or dermis. The skin is subject to injury from a variety of external and internal factors.
CUES NOC NIC EVALUATION
NOC 1: Tissue Integrity: NIC 1a: Infection Control
Objective: Skin & Mucous
 Post-operative Membranes - Ensure appropriate wound care technique
patient of - Instruct patient to take antibiotics, as prescribed
Modified Radical 110102 Sensation - Teach patient and family about signs and symptoms of infection and when to
Mastectomy, 1 2 3 4 5 report them to the health care provider
Right breast - Maintain strict asepsis for dressing changes and wound care
110113 Skin integrity
 Scanty red 1 2 3 4 5 NIC 1b: Incision Site Care
drainage on the
incision site 110111 Tissue perfusion - Inspect the incision site for redness, swelling, or signs of dehiscence or
1 2 3 4 5 evisceration
- Note characteristics of any drainage
Subjective: Legend: - Monitor the healing process in the incision site
 Patient stated - Use sterile, cotton-tipped applicators for efficient cleansing of tight-fitting wire
about “Numb Severely compromised - 1 sutures, deep and narrow wounds, or wounds with pockets
feeling of the Substantially compromised - Change the dressing at appropriate intervals
breast incision - 2 - Apply an appropriate dressing to protect the incision
site” Moderately compromised - - Teach the patient how to minimize stress on the incision site
3 - Teach the patient and/or the family how to care for the incision, including signs
Mildly compromised - 4 and symptoms of infection
Not compromised - 5
NIC 1c: Nutritional Counseling

- Facilitate identification of eating behaviors to be changed

- Discuss patient’s knowledge of the basic four food groups, as well as
perceptions of the needed diet modification
 Discuss to the patient about minimizing carcinogenic foods like fast
foods, barbeque, and processed foods.
 Diet modification focusing on eating green leafy vegetables such as
malunggay, pechay, and kamote tops. Eating egg dishes could also help.
- Determine attitudes and beliefs of significant others about food, eating,
and the patient’s needed nutritional change

14
References
Akram, M., Iqbal, M., Daniyal, M., & Khan, A. (2017). Awareness and current knowledge of breast cancer.
Retrieved from https://link.springer.com/article/10.1186/s40659-017-0140-9

Centers for Disease Control and Prevention. (2021). What is breast cancer. Retrieved from
https://www.cdc.gov/cancer/breast/basic_info/what-is-breast-cancer.htm

Hinkle, J., & Cheever, K. (2018). Brunner & Suddarth's Textbook of Medical-Surgical Nursing 14th Edition .
Philippines: Wolters Kluwer.

Ikhuoria, E., & Bach, C. (2018). Introduction to Breast Carcinogenesis Symptoms, Risks Factors, Treatment and
Management. Retrieved from https://www.ej-eng.org/index.php/ejeng/article/view/745

Lewis, S., Dirksen, S., Heitkemper, M., & Bucher, L. (2014). Medical-Surgical Nursing Assessment and
Management of Clinical Problems. Canada: Elsevier.

Nounou, M., ElAmrawy, F., Ahmed, N., Abdelraouf, K., Goda, S., & Syed-Sha-Qhattal. (2015). Breast Cancer:
Conventional Diagnosis and Treatment Modalities and Recent Patents and Technologies. Retrieved from
https://journals.sagepub.com/doi/full/10.4137/BCBCR.S29420

Singh, S., & Chakrabati R. (2019). Consequences of EMT-Driven Changes in the Immune Microenvironment of
Breast Cancer and Therapeutic Response of Cancer Cells. Retrieved from https://www.mdpi.com/2077-
0383/8/5/642

Thakur, P., Seam, K,. Gupta, MK., Gupta, M., Sharma, M., & Fotedar, V. (2020). Breast cancer risk factor
evaluation in a Western Himalayan state: Acase–control study and comparison with the Western World.
Retrieved from https://www.thieme-connect.com/products/ejournals/pdf/10.4103/sajc.sajc_157_16.pdf

Wilhelmi, B. J,, & Molnar, J. A. (2014). Finger nail and tip injuries. Retrieved from
emedicine.medscape.com/article/1285680-overview

15
APPENDICES

16
A. DRUG STUDY

Prescribed Medication Prescribed Dosage, Frequency and Route of Administration: 40 mg IV

Brand Name: Prilosec, Prilosec OTC
Therapeutic Dosage: Adult: 40mg
Generic Name: Omeprazole
Drug Classification Mechanisms of Action
(General Action) Patient Teaching Nursing Responsibilities
 It works by decreasing the amount
 Advise patient to avoid alcohol and  Monitor improvements in GI symptoms
Proton-pump of acid made in the stomach.
inhibitor foods that may cause an increase in GI (gastritis, heartburn, and so forth) to help
irritation. determine if drug therapy is successful.

 Instruct patient to report bothersome or  Assess dizziness that might affect gait,
prolonged side effects, including skin balance, and other functional activities. Report
problems (itching, rash) or GI effects balance problems and functional limitations to
(nausea, diarrhea, vomiting, the physician, and caution the patient and
constipation, heartburn, flatulence, family/caregivers to guard against falls and
abdominal pain). trauma.

 Monitor other CNS side effects (drowsiness,

fatigue, weakness, headache), and report
severe or prolonged effects.

 Monitor any chest pain and attempt to

determine if pain is drug induced or caused by
cardiovascular dysfunction (e.g., angina that
occurs during exercise).

17
Laboratory Indications
Tests/Results Relevant
to the Medication
 Cause false  Gastric Ulcer
negatives in  GERD
the urea  H. Pylori infection
breath test,  Erosive Esophagitis
stool antigen  Duodenal Ulcer
test

Drug-Drug Food-Drug Interactions

Interactions
Severe Interactions of  Acidic foods and drinks
omeprazole include: such as apples, lemons,
grapefruit, oranges,
 erlotinib tomatoes, wine, lemonade,
 nelfinavir coca-cola, fruit juices and
 rilpivirine energy drinks can make
GERD, heartburn
indigestion symptoms
worse.

18
Prescribed Medication Prescribed Dosage, Frequency and Route of Administration: 10 mg 1 amp IU
Brand Name:
Therapeutic Dosage: 5mg
Generic Name: Metoclopramide
Drug Classification Mechanisms of Action
(General Action) Patient Teaching Nursing Responsibilities
 Stimulates motility of upper GI
 Avoid tasks that require alertness,  Assess for dehydration (poor skin turgor, dry
Dopamine receptor tract. Blocks dopamine/serotonin
antagonist. receptors in chemoreceptor trigger monitor skills until response to drug is mucous membranes, longitudinal furrows in
zone. Enhances acetylcholine
response in upper GI tract; increases established. tongue). Assess for nausea, vomiting,
lower esophageal sphincter tone. abdominal distention, bowel sounds.
Therapeutic Effect: Accelerates
 Report involuntary eye, facial, limb
intestinal transit, promotes gastric
emptying. Relieves nausea, movement (extrapyramidal reaction).  Monitor for anxiety, restlessness,
vomiting.
extrapyramidal symptoms (EPS) during IV
 Avoid alcohol administration.

 Monitor daily pattern of bowel activity, stool

consistency.

 Assess skin for rash. Evaluate for therapeutic

response from gastroparesis (nausea,
vomiting, bloating).

 Monitor renal function, B/P, heart rate.

Laboratory Indications
Tests/Results Relevant
to the Medication
May increase  Prevention of
serum Chemotherapy-Induced
aldosterone, vomiting
prolactin  Post-up nausea

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 Gastroparesis
 GERD

Drug-Drug Food-Drug Interactions

Interactions
Alcohol, other CNS None known
depressants may
increase CNS
depressant effect.
Anticholinergics,
opioid analgesics may
decrease effects

Prescribed Medication Prescribed Dosage, Frequency and Route of Administration: 1.5 gm IVTT ANST
Brand Name: SULTAMICILLIN TOSYLATE Therapeutic Dosage: Usual dose: 375 mg to 750 mg twice daily.

Generic Name: Silgram

Drug Classification Mechanisms of Action
(General Action) Patient Teaching Nursing Responsibilities
ANTIBACTERIAL  Sultamicillin tosylate inhibits  Take this drug around-the-clock.  Culture infected area before treatment; re
beta-lactamases in penicillin-  Take the full course of therapy; do not culture area if response is not as expected.
resistant microorganisms and it stop taking the drug if you feel better.  Check IV site carefully for signs of

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acts against sensitive organisms  Take the oral drug on an empty thrombosis or drug reaction.
during the stage of active stomach, 1 hour before or 2 hours after  Do not give IM injections in the same site;
multiplication by inhibiting meals; do not take with fruit juice or atrophy can occur. Monitor injection sites.
biosynthesis of cell wall soft drinks; the oral solution is stable  Administer oral drug on an empty stomach, 1
mucopeptide. for 7 days at room temperature or 14 hr before or 2 hr after meals with a full glass
days refrigerated. of water; do not give with fruit juice or soft
 This antibiotic is specific to your drinks.
problem and should not be used to
self-treat other infections.
Laboratory Tests/Results Indications
 You may experience these side effects:
Relevant to the Medication
Nausea, vomiting, GI upset (eat
Sultamicillin tosylate is used in frequent small meals), diarrhea.
the treatment of gonococcal
 Report pain or discomfort at sites,
infections, otitis media,
unusual bleeding or bruising, mouth
pyelonephritis, upper and lower
sores, rash, hives, fever, itching,
respiratory tract infections,
severe diarrhea, difficulty breathing.
urinary tract infections, and skin
and soft tissue infections.
Drug-Drug Interactions Food-Drug Interactions

Concurrent use with It comes as a tablet to take by

warfarin and methotrexate mouth, with or without food.
increases risk of bleeding
due to toxicity; efficacy of
estrogen-containing oral
contraceptives is decreased
upon concurrent use;
excretion ampicillin is
reduced when used with
probenecid.

21
Prescribed Medication Prescribed Dosage, Frequency and Route of Administration: 1 cap TID
Brand Name: Hidrasec Therapeutic Dosage: 100 mg tid. Continue treatment until 2 normal stools are recorded. Max
duration of treatment: 7 days.
Generic Name: racecadotril
Drug Classification Mechanisms of Action
(General Action) Patient Teaching Nursing Responsibilities
antidiarrheals Racecadotril is a prodrug of  One capsule initially regardless what  Assess patient’s diarrhea and bowel pattern
thiorphan, an enkephalinase time of the day before starting therapy
inhibitor. It achieves its  One capsule three times daily  Assess hydration status and electrolytes level
antisecretory effect by protecting preferably before the main meals.
enkephalins from enzymatic  Treatment should be continued until 2
degradation thereby prolonging normal stools are recorded
their action at enkephalinergic  Treatment should not exceed 7 days.
synapses in the small intestine
and reducing hypersecretion.

Laboratory Tests/Results Indications

Relevant to the Medication

22
If casual treatment of acute
diarrhea is possible, racecadotril
can be co-administered.
Capsule: Symptomatic treatment
of acute diarrhea in adults.

Drug-Drug Interactions Food-Drug Interactions

Angiotensin converting Food delays peak activity by

enzyme inhibitors (such as approx 90 minutes.
captopril, enalapril,
lisinopril, fosinopril,
perindopril, ramipril) are
known to induce
angioedema. This risk
could be increased in
presence of racecadotril.

In humans, the
concomitant treatment with
racecadotril and
loperamide or nifuroxazide
does not modify the
kinetics of racecadotril.

23
Prescribed Medication Prescribed Dosage, Frequency and Route of Administration: 50 mg 1 tab BID PO
Brand Name: Kenzar Therapeutic Dosage:
HTN 50mg od, may be increased to 100mg daily based on BP response in 1 or 2 divided doses.
Generic Name: Losartan
Drug Classification Mechanisms of Action
(General Action) Patient Teaching Nursing Responsibilities
Angiotensin II Potent vasodilator. Blocks  Pts should take measures to avoid Baseline Assessment
Antagonists vasoconstrictor, aldosterone- pregnancy.  Obtain B/P, apical pulse immediately before
secreting effects of angiotensin  Report pregnancy to physician as soon each dose, in addition to regular monitoring
II, inhibiting binding of as possible. (be alert to fluctuations).
angiotensin II to AT1 receptors.  Avoid tasks that require alertness,  Question for possibility of pregnancy.
Therapeutic Effect: Causes motor skills until response to drug is  Assess medication history (esp. diuretic).
vasodilation, decreases established (possible dizziness effect). Intervention/Evaluation
peripheral resistance, decreases  Report any sign of infection (sore  Maintain hydration (offer fluids frequently).
B/P. throat, fever), chest pain.  Assess for evidence of upper respiratory
 Do not take OTC cold preparations, infection, cough.
nasal decongestants.  Monitor B/P, pulse. If excessive reduction in
 Do not stop taking medication. B/P occurs, place pt in supine position, feet
 Limit salt intake. slightly elevated.
 Assist with ambulation if dizziness occurs.
Monitor daily pattern of bowel activity, stool
consistency.
 Maintain hydration (offer fluids frequently).
 Assess for evidence of upper respiratory
infection, cough.
 Monitor B/P, pulse. If excessive reduction in
B/P occurs, place pt in supine position, feet
slightly elevated.
 Assist with ambulation if dizziness occurs.
Monitor daily pattern of bowel activity, stool
consistency.
Laboratory Tests/Results Indications
Relevant to the Medication

24
Hypertension.

Drug-Drug Interactions Food-Drug Interactions

Drug: Phenobarbital
decreases serum levels of
losartan and its metabolite.

Prescribed Medication Prescribed Dosage, Frequency and Route of Administration: 1 tab BID
Brand Name: Kaligen Therapeutic Dosage: PO: ADULTS, ELDERLY: (Mild to moder- ate): Initially,10–20mEqgiven2–
4times/ day. (Severe): Initially, 40 mEq given 3–4 times/day. (May also give 20 mEq q2–3h in
Generic Name: Potassium Chloride conjunction with careful monitoring.)

Drug Classification Mechanisms of Action

25
(General Action) Patient Teaching Nursing Responsibilities
Necessary for multiple Principal intracellular cation;  Monitor I&O ratio and pattern in  Assess for hypokalemia (weakness, fatigue,
cellular metabolic essential for maintenance of patients receiving the parenteral drug. polyuria, polydipsia). PO should be given
processes. Primary action intracellular isotonicity, If oliguria occurs, stop infusion with food or after meals with full glass of
is intracellular. transmission of nerve impulses, promptly and notify physician. water, fruit juice (minimizes GI irritation).
contraction of cardiac, skeletal,  Lab test: Frequent serum electrolytes  Instruct patient to mix and dissolve powder
and smooth muscles, are warranted. completely in 3 to 8 oz of water or juice.
maintenance of normal kidney  Monitor for and report signs of GI  Tell patient to swallow extended- release
function, and for enzyme ulceration (esophageal or epigastric capsules whole without crushing or chewing
activity. Plays a prominent role pain or hematemesis). them.
in both formation and correction  Monitor patients receiving parenteral  Instruct patient to take oral form with or just
of imbalances in acid–base potassium closely with cardiac after a meal, with a glass of water or fruit
metabolism. monitor. Irregular heartbeat is usually juice.
the earliest clinical indication of  Tell patient to sip diluted liquid form over 5
hyperkalemia. to 10 minutes.
 Be alert for potassium intoxication  Advise patient to report nausea, vomiting,
(hyperkalemia, see S&S, Appendix F); confusion, numbness and tingling, unusual
may result from any therapeutic fatigue or weakness, or a heavy feeling in legs
Laboratory Tests/Results Indications dosage, and the patient may be
Relevant to the Medication asymptomatic.
To prevent and treat potassium  The risk of hyperkalemia with
deficit secondary to diuretic or potassium supplement increases (1) in
corticosteroid therapy. Also older adults because of decremental
indicated when potassium is changes in kidney function associated
depleted by severe vomiting, with aging, (2) when dietary intake of
diarrhea; intestinal drainage, potassium suddenly increases, and (3)
fistulas, or malabsorption; when kidney function is significantly
prolonged diuresis, diabetic compromised.
acidosis. Effective in the 
treatment of hypokalemic
alkalosis (chloride, not the
gluconate).
Drug-Drug Interactions Food-Drug Interactions

26
Drug: POTASSIUM-
SPARING DIURETICS,
ANGIOTENSIN-
CONVERTING ENZYME
(ACE) INHIBITORS may
cause hyperkalemia.

27
B. Nursing Updates

Advances in Breast Cancer Research

NCI-funded researchers are working to advance our understanding of how to prevent, detect, and treat breast
cancer. They are also looking at how to address disparities and improve quality of life for survivors of the disease.

Early Detection of Breast Cancer

Ongoing studies are looking at ways to enhance current breast cancer screening options. Technological
advances in imaging are creating new opportunities for improvements in both screening and early detection.

One new technology is 3-D mammography, also called breast tomosynthesis. This procedure takes images
from different angles around the breast and builds them into a 3-D-like image. Although this technology is
increasingly available in the clinic, it isn’t known whether it is better than standard 2-D mammography, for detecting
cancer at a less advanced stage.

Breast Cancer Treatment

The RxPONDER trial found that the same gene expression test can also be used to determine treatment options
in women with more advanced breast cancer.

Genomic analyses, such as those carried out through The Cancer Genome Atlas (TCGA), have helped reveal
the molecular diversity of breast cancer and eventually could help identify even more breast cancer subtypes. That
knowledge, in turn, may lead to the development of therapies that target the genetic alterations that drive those
cancer subtypes.

Triple-Negative Breast Cancer

Triple-negative breast cancers (TNBC) are the hardest to treat because they lack both hormone receptors and
HER2 overexpression, so they do not respond to therapies directed at these targets. Therefore, chemotherapy is the
mainstay for treatment of TNBC.

Early Detection and Treatment Research

The Breast Specialized Programs of Research Excellence (Breast SPOREs) are designed to quickly move basic
scientific findings into clinical settings. The Breast SPOREs support the development of new therapies and
technologies, and studies to better understand tumor resistance, diagnosis, prognosis, screening, prevention, and
treatment of breast cancer.

The NCI Cancer Intervention and Surveillance Modeling Network (CISNET) focuses on using modeling to
improve our understanding of how prevention, early detection, screening, and treatment affect breast cancer
outcomes.

The Consortium for Imaging and Biomarkers (CIB) and the Consortium for Molecular Characterization of
Screen-Detected Lesions are programs that research which screen-detected lesions are areas of concern and which
can be left alone. The goal of the programs is to give physicians a better idea whether regular monitoring is
sufficient or if early treatment is warranted.

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