I.

INTRODUCTION

A. BACKGROUND OF THE STUDY

i. Incidence, race, gender, age, ration and proportion

Cancer is a major health problem worldwide and the morbidity and mortality from cancer
give rise to much suffering. The risk of developing cancer in an individual's lifetime is about
33%, and the risk of dying of cancer is 25%. Cancer is not only a disease of the elderly although
for many cancers the incidence increases with age. Breast cancer is the most common
malignancy in women and the second leading cause of cancer death, exceeded only by lung
cancer in 1985. One woman in eight who lives to age 85 will develop breast cancer at some time
during her life.

Breast cancer (malignant breast neoplasm) is a cancer originating from breast tissue, most
commonly from the inner lining of milk ducts or the lobules that supply the ducts with milk.
Cancers originating from ducts are known as ductal carcinomas; those originating from lobules
are known as lobular carcinomas. There are many different types of breast cancer, with different
stages (spread), aggressiveness, and genetic makeup; survival varies greatly depending on those
factors. Computerized models are available to predict survival. With best treatment and
dependent on staging, 10-year disease-free survival varies from 98% to 10%. Treatment includes
surgery, drugs (hormonal therapy and chemotherapy), and radiation.

In Asia, the Republic of the Philippines has the highest reported incidence rate of breast
cancer. From 43.2 in 2003-2005, the age standardized-incidence rate (ASR) is now 47.7 per
100,000 females, and this figure exceeds the rate reported for several Western countries,
including Spain, Italy, and most Eastern European countries. Many breast cancers are diagnosed
among 35 to 50-year-old Filipino women. In terms of breast cancer detection, a local study
revealed that the use of breast self-examination (BSE) and aspiration biopsy/open biopsy are the
most cost-effective strategies in the Philippine setting, incurring savings for the government by
almost 3 million Philippine Pesos or US $60,000 (1989 value) per year per 100,000 women.
Mammography is neither readily available nor affordable especially in the rural areas.

B. RATIONALE FOR CHOOSING THE CASE

I have chosen the case because I want to broaden my knowledge about Breast Cancer
regarding to the nursing interventions and medical management. Cancer is the second leading
cause of death and is a common case in the E-Ward of Quezon Medical Center that also
prompted the group to research on the disease. The risk of developing most types of cancer can
be reduced by changes in a person's lifestyle, for example, by quitting smoking and eating a
better diet. The sooner a cancer is found and treatment begins, the better are the chances for
living for many years.
C. SIGNIFICANCE OF THE STUDY

To be able to give importance and attention to the concerns and needs of our patient and our
patients family members through therapeutic communication.

To successfully come up with the written output of this case study and be able to attain the
general objectives, the group aims to:

1. Gather information and pertinent data from the patients chart and the significant others
by interviewing them.
2. Trace the family health history and family background of the patient.
3. Identify effects or expectations of the illness to the patient herself and her family.
4. Trace the health history of the patient, including the history of past illnesses and history
of present illness.
5. Perform and discuss a complete, thorough and comprehensive physical assessment by
using inspection, percussion, palpation and auscultation cephalocaudally.
6. Trace the pathophysiology of the patients diagnosis which would also include the
precipitating and predisposing factors of the patients condition
7. Research on drug studies on the drugs given to the patient which would include the
generic name of the drug, its brand name(s), therapeutic and pharmacological
classification, dosage and frequency, the mechanism of action of the drug, indications,
contraindications, side effects, adverse reactions, and Nursing responsibilities for each
drug.
8. Formulate appropriate nursing care plans through the utilization of the various nursing
theories related to the case of the patient.
9. Provide health teachings and recommendations for the patient and significant others.
10. Formulate a discharge plan using M.E.T.H.O.D.

D. SCOPE AND LIMITATION OF THE STUDY

The study would only focus on Breast Cancer which is indicative to the clients health
condition and its underlying nursing care relevant for the client within the 4 days of duty at
Quezon Medical Center.

E. CONCEPTUAL OR THEORETICAL THEORY

THEORETICAL FRAMEWORK

Jean Watsons (1979-1985) Theory of Human Caring.

She emphasized that nursing is the application of the art and human science through
transpersonal caring transactions to help persons achieve mind-body-soul harmony, which
generates self-knowledge, self-control, self-care, and self-healing. She included health promotion
and treatment of illness in nursing. She believed that a person is a valued being to be cared for,
respected, nurtured, understood and assisted; a fully functional integrated self.
The Ten Carative factors, transpersonal caring relationship and the caring occasion constitute the
elements of Jean Watsons Theory of Human Caring. Her ten carative factors are viewed as the
guide of a nurse in honoring the human dimensions of nursings work and the inner life world.
These carative factors point to the aspects of nursing which affect the one caring and the one
being cared for thereby potentiating the therapeutic healing processes. The ten carative factors
included in her work are the following:

1. Formation of a humanistic-altruistic system of values.

2. Instillation of faith-hope.
3. Cultivation of sensitivity to ones self and to others.
4. Development of a helping-trusting, human caring relationship.
5. Promotion and acceptance of the expression of positive and negative feelings.
6. Systematic use f a creative problem-solving caring process.
7. Promotion of transpersonal-teaching learning.
8. Provision of a supportive, protective and corrective mental, physical , societal and
spiritual environment.
9. Assistance with gratification of human needs.
10. Allowance for existential-phenomenological spiritual forces (Watson, 1979).

F. RELATED LITERATURE

BONE METASTASIS

Bone metastasis occurs when cancer cells spread from their original site to a bone.
Nearly all types of cancer can spread (metastasize) to the bones. But some types of cancer
are particularly likely to spread to bone, including breast cancer and prostate cancer.
Bone metastasis can occur in any bone but more commonly occurs in the spine, pelvis
and thigh. Bone metastasis may be the first sign that you have cancer, or bone metastasis
may occur years after cancer treatment. Bone metastasis can cause pain and broken
bones. With rare exceptions, cancer that has spread to the bones can't be cured.
Treatments can help reduce pain and other symptoms of bone metastases.

Signs and Symptoms:

Bone pain
Broken bones
Urinary incontinence
Bowel incontinence
Weakness in the legs or arms
High levels of calcium in the blood (hypercalcemia), which can cause nausea,
vomiting, constipation and confusion
Risk Factors:

Virtually any type of cancer can spread to the bones, but the cancers most likely to cause bone
metastasis include:
 Breast cancer
Kidney cancer
Lung cancer
Lymphoma
Multiple myeloma
Prostate cancer
Thyroid cancer

PNEUMONIA

Pneumonia is an infection of the air sacs in your lungs. The infection causes inflammation
(swelling) of the lung tissue and can affect breathing and oxygen exchange. These infections are
most commonly caused by bacteria, but can also be caused by viruses or fungi. Pneumonia can
affect one or both lungs.

Pneumonia causes different symptoms based on patient factors and what germ or bug is
causing the infection. Severity of symptoms can range from mild to life-threatening. Many of
pneumonias symptoms are similar to other less serious respiratory infections.

Symptoms of pneumonia include:

Fever
Discomfort
Chills or sweating
Cough that produces a thick, sticky fluid
Diarrhea
Nausea
Vomiting
Muscle fatigue
Chest pain
Muscle aches
Fatigue

Treating Pneumonia:

Pneumonia in stage 4 breast cancer can be treated, but cancer patients have a weakened immune
system so they are at a higher risk of complications and may need to be hospitalized for
treatment.

Common treatments for pneumonia include:

Antibiotics, to treat pneumonia caused by bacteria (several types of bacteria can cause
pneumonia, so your doctor will need to conduct tests to determine the type of antibiotic
you need)
Antifungal medicines, to treat pneumonia caused by a fungal infection
 Viral pneumonia is usually treated with supportive measures like fluids, oxygen if
needed, as well as medicines that help relieve the symptoms of pneumonia like fever and
cough
Cough medicine, to help relieve this common symptom, and over-the-counter medicine
such as ibuprofen and aspirin to reduce fever and discomfort associated with pneumonia.

II. CLINICAL SUMMARY

A. GENERAL DATA PROFILE

Name: Mrs. Hopeless
Age: 60
Address: Harvard Ext. Site, LC
Nationality: Filipino
Religion: Roman Catholic
Civil Status: Married
Occupation: Bank Manager
Date of admission: March 18, 2017
Admitting diagnosis: Invasive ductal CA L
Admitting Physician: Dr. Dizon

B. CHIEF COMPLAIN

Prior to admission the patient experienced severe pain on the left breast with mass, with pain
scale of 10, 10 as the highest and 0 as the lowest.

C. NURSING HISTORY

i. History of present illness

Admitted for several times from e-ward per wheel chair accompanied by husband, for 3rd
cycle chemotherapy.
Physical examination was done and she was diagnosed with Breast Cancer.

Childhood illness: Cough, cold, fever

Immunizations: complete
Allergies: none
Accidents: none
Hospitalizations: Several times at QMC
Medications used or currently taking: Paracetamol, Neuzep, antibiotics, vitamins
and tamoxifen citrate

D. FAMILY HISTORY

All information regarding the familys health history comes from Patient X. According to her,
no one in the past two generations has had a breast cancer. All the sicknesses she recalls are
from her fathers side; one aunt has diabetes and one uncle has kidney failure. Among her
siblings, the second and the third eldest sons have hypertension.

E. SOCIAL HISTORY - INCLUDE THEORIES ON GROWTH AND DEVELEOPMENT

PSYCHOSOCIAL THEORY ACCORDING TO ERIK ERIKSON

Stage Age Central Task Indicators of Indicators of

Positive Negative
Resolution Resolution
Middle 40 - 65 Generativity To have and An individual
Adulthood years vs. Stagnation nurture children must deal with
and/or become issues they are
involved with concerned with
future generations or it can lead to
stagnation in
later life

According to this theory by Erikson, the middle adulthood stage correlates to the patients
age because she established her career, settle down within a relationship, she has a own family
and she developed a sense of being a part of the bigger picture.

ACCORDING TO SIGMUND FREUD

Stage Age Characteristics Implication
Genital 11 years old Engage in appropriate Develops with the
-onwards sexual behavior, which physiology changes
may lead to marriage
and childbirth

According to this theory by Freud, the genital stage correlates to the patients age because
she is married to his husband and she has a child.

F. ENVIRONMENT/LIVING CONDITION

Mrs. Hopeless is married and with four children. They are living in a bungalow type of house
made of cement and wood just. Purchase of mineral water is their source of drinking water in the
area. She also Garbage is collected on their area daily. She is fond of eating vegetables and fruits,
less meat, and fish, and very selective on food. She dislikes and avoids eating salty foods; she is
not very fond of eating sweets. She also stated that promotes drinking water, hydrating herself by
drinking lots of water approximately 8-10 glasses a day, as she knows that it would be a benefit
to her health. She also stated that she is a non-alcoholic and non-smoker.
G.PHYSICAL ASSESSMENT

Parameters Normal findings Actual findings Interpretation

General appearance > Clean in > Slightly thin Patient loss weight
appearance & well approximately from due to
groomed 55kg-47kg hospitalization.
> Cooperative
Skin > With good skin > With bad skin
turgor turgor
Hair > Evenly distributed >With loss and thin Patient thin hair due
hair hair to chemotherapy
> Thick hair
Nails > With good > With capillary Patient experiencing
capillary refill of 1-2 refill of 4-5 seconds cyanosis
seconds > With slightly
> With pinkish nail bluish nail beds
beds
> With clean and
short nails
Skull and face > Mouth uniform >Asymmetrical
consistency: absence facial movement
of nodules and
masses
> Rounded smooth
skull contour
> Symmetrical facial
movement
Eyes > No eye discharge >Withh yellowish Patient bilirubin is
> With anicteric sclera elevated
sclera >With pale
> Eyebrow hair conjunctiva
evenly
distributed/skin
intact
> (+) blink reflex
> With pinkish
conjunctiva
Ears > Auricle color same
as facial skin
> Auricle is mobile
firm and not tender
> Able to hear on
both ears
> No edema &
discharge
Mouth > Pinkish lips > Dry lips
 > Without missing > With on and off
teeth productive cough
> With pink gums >With asymmetrical
> No foul odor contour
> With symmetrical
contour
Musculoskeletal > Symmetrical >Asymmetrical Patient is
(Upper and lower > No atrophy >With atrophy of experiencing body
extremities) > With full range of upper extrimities weakness
motion >Decreased range of
motion
Abdomen > No abdominal >With abdominal
distention distention
> With globular >With asymmetrical
abdomen contour
> Symmetrical
contour
> No surgical
incision

H. PATTERNS OF FUNCTIONING

Functional Health Before During Interpretation

Pattern Hospitalization Hospitalization
Health management > Self-medication > Been hospitalized It was her 5th
pattern a number of times hospital experience,
before she values health
> She realizes that and her health status
it is a must to take somehow gave her
responsibility in our realization that
health. Our health actions of staying
reflects the healthy is more
consequences of our important than just
actions. merely knowing on
how to be healthy.

Nutritional/Metaboli > More than 3 times >Once a day Some of her

c a day > With loss appetite medication
a. No. Of meals > With very good > 2 glasses of water suppresses her
per day appetite > With small body appetite which
b. Appetite > 8 glasses of water built for his age aggravates her usual
c. Glass of water > With slightly > 155cm and 47kg. appetite even before
per day bigger body built for hospitalization.
d. Body built his age
e. Height and > 165cm and 55kg.
weight
Elimination > 4-5 times per day > 2-3 times per day Changes in bowel
a. Frequency of >Moderate > Scanty movement is due to
urination. > Once a day > Once a week decrease mobility or
b. Amount of urine > Formed > Slightly soft exercise.
per day > Moderate > Scanty
c. Frequency of
bowel movement
d. Consistency of
the feces
e. Amount defecated
per day
Activity and > No active exercise > No isometric and Her body is still
exercise everyday active exercise weak brought about
a. Exercise > Easily get tired > Easily get tired prolonged disease
b. Fatigability > Independent >Dependent process and decline
c. ADL of her body system.

Cognitive/ > Oriented to time, > Not responding to No change, since the
Perceptual place and person verbal and physical operation performed
a. Orientation > Respond stimuli was localized at her
b. Responsiveness appropriately to breast.
verbal and physical
stimuli
Roles/ Relationship > With good > She sometimes Being an optimist
a. As a wife relationship to her feels sad and fears and dependable
b. As a mother husband that she might not person, she values
> With good be able to perform relationship with
relationship to her her role in the others regardless of
son and daughter. family.. her condition,
however, she cant
help to have fears to
the anticipated
procedures she have
to undergo if her
illness will get
worse.
Self-perception/Self > Have a high self- > Shes strong Her personality as a
concept worth/importance enough to accept her strong-willed person
illness, however, she somehow helps her
admits that there are to accept her
times when she just condition but
lose hopes, but tries nevertheless, as part
her best not to show of a woman it is
it to her family. expected for her to
be emotional at
times.
Coping/Stress > She seeks for > Her family She is a family-
some advice her supports her and she oriented person. She
friends and relatives tries her best to stay values her family
when he has a strong for them. She and her faith, which
problems, burdens had a strong faith in influenced her
and stresses. God and its one of coping mechanism
the reasons that in dealing with lifes
keep her going. unexpected
challenges.

Values/ Beliefs > She is awareness > Her awareness to The values she had
that God really God became remains with her no
exist. stronger than before matter how difficult
things are.

I.. LABORATORY/DIAGNOSTIC EXAM

Hematology
Date of examination: March 18, 2017

Normal Result Interpretation

values
Hemoglobin 120-160 145 Normal- adequate oxygen-carrying protein and
gm/L deliver it to the body tissue
Hematocrit 0.37- 0.47 0.44 Normal- adequate proportion of total blood volume
made up of red blood cell.
Lymphocyte 0.20- 0.40 0.30 Normal- No presence of infection.
Eosinophil 0.01-0.05 0.07 Due to presence of Neoplastic disease.
Basophils 0.0-0.01 0.01 Normal

Urinalysis
Date of examination: March 18, 2017
Color: Yellow
Transparency: Turbid
Ph: 7.5
Specific Gravity: 1.005

Chest X-ray
Date of examination: March 20, 20017
Findings: Pleural effusion Bilateral
SPECIAL PROCEDURE

THORACENTESIS - is an invasive procedure to remove fluid or air from the pleural

space for diagnostic or therapeutic purposes.
*The most common causes of pleural effusions are cancer, congestive heart failure, pneumonia,
and recent surgery.

Date: March 21, 2017

J. IMPRESSION/DIAGNOSIS

Disturbed Body Image related to loss of breast

III. CLINICAL DISCUSSION OF THE DISEASE

ANATOMY AND PHYSIOLOGY

Female Breast

The breast is an organ which whose structure reflects its special function: the production of
milk for lactation. The epithelial component of the tissue consists of lobules, where milk is made,
which connect to ducts that lead out to the nipple. Most cancers of the breast arise from the cells
which form the lobules and terminal ducts. These lobules and ducts are located spread
throughout the background fibrous tissue and adipose tissue (fat) that make up the main mass of
the breast. The structure of the male breast is nearly identical to that of the female breast, except
that the male breast tissue lacks the specialized lobules, as there is no physiologic need for milk
production by the male breast.

Anatomically, the adult breast sits atop the pectoralis muscle (the "pec" chest muscle), atop
the ribcage. The breast tissue extends horizontally (side-to-side) from the edge of the sternum
(the firm flat bone in the middle of the chest) out to the midaxillary line (the center of the axilla,
or under arm). It is important to note that a tail of breast tissue called the "axillary tail of Spence
does extend into the axilla. This is important because a mass of breast cancer can develop in this
axillary tail, even though it might not seem to be in the breast proper.

The breast tissue is encircled by a thin layer of connective tissue called fascia. The deep layer
of this fascia sits immediately on top of the pectoralis muscle, and the superficial layer sits just
under the skin. The skin covering the breast is similar to skin elsewhere on the torso and has
similar sweat glands, hair follicles, and other characteristic features. A clinician will examine the
skin in addition to the breast tissue itself when performing a breast exam.

The blood supply from the breast comes primarily from the internal mammary artery, which
runs underneath the main breast tissue. The blood supply provides nutrients, such as oxygen, to
the breast tissue. The lymphatic vessels of the breast flow in the opposite direction of the blood
supply and drain into lymph nodes. It is through these lymphatic vessels that breast cancers
metastasize to lymph nodes. Most lymphatic vessels flow to the axillary (under arm) lymph
nodes, while a smaller number of lymphatic vessels flow to internal mammary lymph nodes
located deep to the breast. Knowledge of this lymphatic drainage is important, because when a
breast cancer metastasizes, it usually involves the first lymph node in the chain of lymph nodes.
This is called the "sentinel lymph node, and a surgeon may remove this lymph node to check for
metastases in a patient with breast cancer.

Physiologically, the breast is an organ specialized for milk formation (lactation). Many
additional changes are seen in the breast tissue during pregnancy and lactation due to the changes
in hormones during those times.
The Lymphatic System

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

Breast cancer cells can enter lymphatic vessels and begin to grow in lymph nodes. Most
lymphatic vessels in the breast connect to lymph nodes under the arm (axillary nodes).Some
lymphatic vessels connect to lymph nodes inside the chest (internal mammary nodes) and those
either above or below the collarbone (supraclavicular or infraclavicular nodes).
2. PATHOPHYSIOLOGY (BOOK/BASED/CLIENT BASED)

PATHOPHYSIOLOGY (book based)

 PATHOPHYSIOLOGY (client based)

PREDISPOSING FACTORS:
Age: 60
Gender: Female
PRECIPITATING FACTORS:
Unknown

Neoplasm formation in the breast

Primary tumor begin in the breast

Surgery
(Pt. undergone mastectomy) Tumor becomes invasive

Travel (metastasize) to other Progress beyond breast to regional lymph nodes

organ systems in the body

It becomes systemic

Primary cancer spreads

Chemotherapy Progress beyond breast to regional lymph nodes

Radiotherapy
Interstitial laser thermotherapy

Removal of the breast Cancer cell spreads into major organs

Cancer cell destroyed/ removed Some cancer cell remains

Cancer cell spreads into major organs

LUNGS LIVER
S/Sx: DOB, S/Sx: RLQ pain
Cough,
Pleural Efussion

BONES BRAIN
S/Sx: Back & bone pain S/Sx: Headache

NECK
S/Sx: Horseness of
voice

3. DRUG STUDY

4. NURSING PROCESS

A. LONGTERM OBJECTIVES
After 1 week of nursing intervention the patients cough will stop and child will be
able to clear airways as evidence by effective breathing pattern.

B. PRIORITIZED LIST NURSING PROBLEMS

Problem Ranking Justification

1
2
C. DISCHARGE PLAN ( M.E.T.H.O.D )

M-ethod
Give adequate instructions to the significant others about the importance of the
following medications and dietary regimens so that the patients condition can
remain stable as soon as possible.

E-nvironment.
Encourage or teach the patient the proper breathing exercises.
Allow the patient to verbalize her feelings.

T-reatment
Chemotherapy
Encourage the patient to have a strict compliance with regards to the medication
to attain therapeutic effects.

H-ealth Teaching
Practice good general hygiene.
Advise to have a clean, quiet, well ventilated room, conductive to rest and
relaxation.

O-ut Patient Referral Check-up

Instruct the patient and family to return to their attending physician for
scheduled follow up visit.

D-iet
Low salt, low fat.
DM diet @ 1000 Kcal /day