THEORETICAL BACKGROUND

OF CHONGESTIVE HEART FAILURE

By

NIRMAYA SOFA

1614401110054

UNIVERSITY OF MUHAMMADIYAH BANJARMASIN

INTERNATIONAL CLASS OF NURSING DIPLOMA PROGRAM

ACADEMIC YEAR 2017/2018

 ADVISOR’S APROVAL

Name : Nirmaya Sofa

SRN : 1614401110054

Ward/Hospital : Camar/Idaman Hospital Banjarbaru

Theoretical Background’s Title : Theoretical Background of Chongestive Heart Failure

Nursing Care Report’s Title : Nursing Care Report on Mr. S with Chongestive Heart
Failure in Camar Ward Idaman Hospital Banjarbaru

Has completed all reports of basic nursing stages in this ward

Banjarmasin, January 25, 2018

Student

(Nirmaya Sofa)

Known By

Advisor CI Advisor CT

( ) ( )

NIK: NIK: 01.24121984.059.002.011

 THEORITICAL BACKGROUND

OF FAM

A. Disease’s Concept

1. Anatomy and Physiology Breast

The breast lies on top of the pectoralis major muscle. Fibrous stroma provides the
background architecture of the breast. Cooper's ligaments are attached to both the fascia of the
skin and the pectoralis major muscle. Carcinoma invading these ligaments may result in skin
dimpling which could be subtle or obvious during visual inspection. (Figure 1)

Figure 1. Carcinoma may result in skin dimpling.

Internal Anatomy

Where does breast cancer originate?

The breast is composed of glandular ducts and lobules, connective tissue, and fat, with
most of the benign and malignant pathology arising in the duct and lobular network (Figure 2).
Specifically, most breast cancer is thought to originate in the terminal ductal lobular unit
(TDLU).
 Figure 2. The breast is composed of glandular ducts and lobules, connective tissue,
and fat.

Half of this glandular tissue is located in the upper outer quadrant; therefore, nearly one half
of all breast cancers occur in this area.

Glandular tissue and fat vary with a woman's age and weight. Lobes, lobules, and acini
serve to produce and secrete milk—the primary function of the breast mammary glands. Ducts
and lactiferous sinuses are tubular connections between the lobes and nipples to allow milk to
exit the breast. The lactiferous sinuses (located beneath the nipple) may contribute to feeling
granularity under the areola on physical examination. The parenchyma of the breast is
composed of these ductal/glandular structures. Adipose tissue is present throughout the breast.
A high ratio of ductal/glandular breast tissue to adipose and fibrous tissue makes detection of
abnormalities during clinical breast examination (CBE) and mammography more difficult,
especially in premenopausal women.

All women, regardless of breast size, have the same number of lobes, approximately 15-25.
Six to 10 major ducts exit the nipple.

2. Definition of FAM

FAM or Fibroadenoma Mammae is a benign breast lesion but is not part of

fibrocystic change (Figure 3). Fibroadenoma represents a focal hyperplasia of the stroma and
the epithelial component of the TDLU and creates a distinctive round and well-circumscribed
mass on physical exam or mammogram. The stromal hyperplasia often compresses and
stretches the hyperplastic glands, creating the fibroadenoma's characteristic histologic pattern.
With age, the stroma will become more sclerotic and may undergo dystrophic calcification,
and the epithelial hyperplasia may decrease. When a fibroadenoma contains cysts, sclerosing
adenosis, epithelial calcifications, or papillary apocrine changes, it is referred to as a complex
fibroadenoma and there is a slightly increased risk in the development of breast cancer.

Figure 3. Fibroadenoma.

Fibroadenoma is one of the most common benign lesions misdiagnosed as carcinoma

because it may occur in women over 50 years of age. It occurs in a wide age range but is
uncommon in children. The imaging features of a smooth hypo-echoic mass are usually
characteristic. On ultrasound examination, fibroadenomas typically appear as an elliptical
mass with smooth borders orientated parallel to the chest wall and exhibit acoustic
hypoechogenicity. These imaging features reflect the gross morphology of the lesion. It is the
most common solid mass in the breast that is sampled by FNA.

Histologically, a fibroadenoma is composed of ducts surrounded and compressed by

proliferated stromal tissue that forms nodules and club-shaped formations. The ducts within a
fibroadenoma are always lined by a dual layer of inner luminal and outer myoepithelial cells
and can show varying degrees of epithelial hyperplasia. In some tumours a florid proliferation
of epithelial cells is observed.

3. Pathway

The cause of fibroadenomas is unknown, but they might be related to reproductive

hormones. Fibroadenomas occur more often during your reproductive years, can become
bigger during pregnancy or with use of hormone therapy, and might shrink after menopause,
when hormone levels decrease
 Hormones such as estrogen may play a part in the growth and development of the
tumors. Taking oral contraceptives before the age of 20 has been associated with a higher risk
of developing fibroadenomas as well. These tumors may grow, particularly during pregnancy.
During menopause, they often shrink. It’s also possible for fibroadenomas to resolve on their
own.

Fibroadenoma is a benign tumor that describes a process of hyperplasia and

proliferation in a single terminal duct, its development being associated with a normal
developmental aberration process. The cause of duct proliferation is unknown, estimated
neoplastic stromal cells secrete growth factors that affect epithelial cells. An absolute increase
in estrogen activity, thought to play a role in its formation. Approximately 10% of
fibroadenomas will disappear spontaneously each year and most fibroadenoma developments
stop after reaching 2 - 3 cm diameter. Fibroadenomas almost never become malignant.

Fibroadenoma is rare in women who have postmenopausal and may develop coarse
calcification features. In contrast, fibroadenoma can develop rapidly during pregnancy, in
hormone replacement therapy, and in immunocompromised individuals, even in some cases,
can cause malignancy. In patients with impaired immunity, fibroadenoma development is
associated with Epstein-Barr virus infection.
 4. Supporting investigation / Diagnostic

During a clinical breast exam, your doctor will check both breasts for lumps and other
problems. Some fibroadenomas are too small to feel, so they can only be discovered in
imaging tests. If you have a lump that can be felt (palpable), your doctor might recommend
certain tests or procedures, depending on your age and the characteristics of the lump.

Tests to evaluate the breast lump

 Diagnostic mammography. Mammography uses X-rays to produce an image

(mammogram) of suspicious areas in your breast tissue. A fibroadenoma might
appear on a mammogram as a breast mass with smooth, round edges, distinct from
surrounding breast tissue.
  Breast ultrasound. This technology uses sound waves to produce pictures of the
inside of the breast. Your doctor might recommend a breast ultrasound in addition to
a mammogram to evaluate a breast lump if you have dense breast tissue.

 Laboratory

o LED increases.
o The alkaline pospalse serum increases.
o Hypercalcaemia..

 Chest X-ray and other tools (To determine whether or not there is metastasis).

For women younger than 30 who have a breast lump, the doctor likely will order a
breast ultrasound first to evaluate the lump. If a mammogram indicates that you have a breast
lump or other abnormality, a breast ultrasound might be used to further assess the lump. A
breast ultrasound can help your doctor determine whether a breast lump is solid or filled with
fluid. A solid mass is more likely a fibroadenoma; a fluid-filled mass is more likely a cyst.

A biopsy may be done to get a definite diagnosis. Different types of biopsies include:

 Excisional (removal of the lump by a surgeon)

 Stereotactic (needle biopsy using a machine like a mammogram)

 Ultrasound-guided (needle biopsy using ultrasound)

 Women in their teens or early 20s may not need a biopsy if the lump goes away on its
own or if the lump does not change over a long period

5. Medical Management
In many cases, fibroadenomas require no treatment. However, some women choose surgical
removal for their peace of mind.

The doctor might recommend surgery to remove the fibroadenoma if one of the tests — the
clinical breast exam, an imaging test or a biopsy — is abnormal or if the fibroadenoma is
extremely large, gets bigger or causes symptoms.

Procedures to remove a fibroadenoma include:

  Lumpectomy or excisional biopsy. In this procedure, a surgeon removes breast tissue
and sends it to a lab to check for cancer.

 Cryoablation. Your doctor inserts a thin, wand-like device (cryoprobe) through your
skin to the fibroadenoma. A gas is used to freeze and destroy the tissue.

After a fibroadenoma is removed, it's possible for one or more new fibroadenomas to
develop. New breast lumps need to be assessed with a mammogram, ultrasound and possibly
biopsy — to determine if the lump is a fibroadenoma or might become cancerous.

B. The Basic Concept of Nursing Care

1. Assessment
a. Nursing History
 Past Health History
Possible clients ever get the rays radiation on the breasts. There are times
when clients get therapy hormones to get children.
 Recent Health History
Clients with post FAM will be in pain because of surgical procedures,
decreased activity, decreased appetite, stress / fear of disease and hope that
will come.
 Family Health History
Although FAM is not a hereditary disease but statistics will show that FAM
is often found on women who have a family relationship.

b. Physical Examination
 Integumentary System.
1. Inspection
 Pain, swelling, phlebitis, ulcers.
 Redness & itching, erythema.
 Skin pigmentation
 Conditions of gums, teeth, mucosa & tongue.
 Gastrointestinal System
1. Assess the frequency, start, duration, severity of nausea & vomiting
after chemotherapy.
2. Observe changes in fluid & electrolyte balance
3. Assess diarrhea & constipation
4. Assess anorexia
5. Assess: jaundice, right upper right quadrant abdominal pain
  Hematopoetic System.
1. Assess Netropenia
 Assess for signs of infection
 Auscultation of the lung
 Look at productive cough & breath dispnoe
 Assess temperature
2. Assess Trombositopenia: <50.000 / m3 - medium, <20.000 / m3 –
weight
3. Assess Anemia
 Skin color, capillary refill
 Dispnoe, weakness, palpitations, vertigo
 Respiratory & Cardiovascular System
1. Assess for marked pulmonary fibrosis: Dispnoe, dry, non productive
cough - especially bleomycin
2. Assess the sign of CHF
3. Perform an EKG examination
 The Neuromuscular System
1. Notice any changes in motor activity
2. Notice the existence of paresthesia
3. Reflex evaluation
4. Assess ataxia, weak, dragging feet
5. Assess for hearing loss
6. Discuss ADL
 The genitourinary system
1. Assess the frequency of BAK
2. Note the smell, color, urine turbidity
3. Assess: hematuria, oliguria, anuria
4. Monitor BUN, creatinine

c. Supporting investigation / Diagnostic

 Diagnostic mammography
 Breast ultrasound
 Laboratory
o LED increases.
o The alkaline pospalse serum increases.
o Hypercalcaemia.
 Chest X-ray and other tools (To determine whether or not there is
metastasis).
2. Nursing Diagnosis

Diagnose 1: Impaired comfort related to nerve tissue damage

Diagnose 2: Acute pain related to fibroadenoma mammae

Diagnose 3: Damage to tissue integrity related to surgical procedures

Diagnose 4: Body image disturbance related to surgery

3. Nursing Interventions
Diagnose 1, Impaired comfort related to nerve tissue damage
Goals: After getting treatment for 2 days the problem of pain relief pain is overcome
Result: After getting treatment for 2x24 hours, pain relief problem can be overcome
with criteria:

NOC Label: Pain Level

 The frequency of client pain decreases

 The client does not seem to wince

NOC Tags: Comfor Status: Physical

 Client can control the symptoms

 Relaxation of the client muscle

NOC Label >> Comfort status: physical

 Symptom control

NOC Label >> Comfort status: psychospiritual

 Internal self-description
 Fear
INTERVENTION RATIONAL
NIC label: Pain Management 1. Reduce the scale of pain felt by the
1. Ensure that patients get the analgesic client
appropriately 2. Prevent client pain getting worse
2. Exploring factors that can aggravate 3. Provide techniques to deal with pain
clients' pain in the client
3. Teach the principles in managing pain
NIC label: Environmental 1. Provide a comfortable temperature
Management Comfort for the patient more relaxed
1. Set the room temperature at a 2. Prevent the emergence or worsen the
comfortable temperature for the client bad feeling of discomfort to the client
2. Reduce the things that can interfere
with the client's convenience
NIC Label: Pruritis Management
1. Determine the cause of the itchiness
2. Use anti-pruritic creams and lotions
according to medication
3. Instruct the client to avoid sweating by
avoiding hot weather and excessive
activity
4. Use an antihistamine cream
NIC Labels >> Anxiety Reduction: .
1. A convincing and reassuring approach
2. Describe all procedures, including
sensations that may be experienced
during the procedure
3. Assess client views regarding stressful
situations
4. Provide factual information on
diagnosis, treatment, and prognosis
5. Encourage families to be with patients
6. Encourages the verbalization of
feelings, perceptions, and fears
7. Identify when anxiety level changes
8. Provide diversion activities directed at
reducing tension
9. Helps patients identify situations that
trigger anxiety
10. Support the use of appropriate
defense mechanisms
11. Advise patients on the use of
relaxation techniques
12. Assess verbal and nonverbal signs of
anxiety
Diagnose 2: Acute pain related to fibroadenoma mammae

Goals: After being given nursing care nursing care for 2x 24 hours, the pain felt by
clients decreased with

Result:

NOC label: Pain Control

 Clients report reduced pain

 The client can recognize the duration (onset) of pain
 The client can describe the underlying factors
 Clients can use non-pharmacological techniques
 Clients use appropriate analgesic instructions

NOC label: Pain Level

 Clients report reduced pain

 The client does not seem to complain and cry
 The facial expression of the client shows no pain
 The client is not nervous

INTERVENTION RATIONAL
NIC Label : Pain Management
Assess comprehensively against pain To know the patient's pain level
including location, characteristics,
duration, frequency, quality, pain intensity
and precipitation factors
Observe the reaction of nonverbal To know the level of discomfort felt by
discomfort the patient
Use therapeutic communication strategies To distract the patient from the pain
to express the pain experience and client
acceptance of the pain response
Determine the effect of the experience of To find out if the pain felt by the client
pain on quality of life (appetite, sleep, affects the others
activity, mood, social relations)
Determine factors that can aggravate pain To reduce the factors that can aggravate
Perform evaluation with clients and other the pain felt by the client
health teams about the size of pain control
that has been done
Give information about the pain including Providing "health education" can reduce
the cause of the pain, how long the pain anxiety levels and assist clients in shaping
will be gone, the anticipation of the the coping mechanisms of pain
discomfort of the procedure
Control environment that can affect client To reduce the level of inconvenience felt
inconvenience response (room by the client
temperature, light and sound)
Eliminate precipitation factors that can So that the pain felt by the client does not
improve the client's pain experience (fear, increase
lack of knowledge)
Teach how to use non-pharmacological So that clients are able to use non-
therapy (distraction, guide imagery, pharmacological techniques in managing
relaxation) the perceived pain
Collaboration of analgesic administration Giving analgesics can reduce the patient's
pain

Diagnose 3: Damage to tissue integrity related to surgical procedures

Goals: After treatment for 3 days the problem of tissue / skin integrity is solved

Results: After care for 3 X 24 hours the problem of tissue / skin integrity can be solved
with criteria:

NOC Labels >> Tissue Integrity: Skin & mucous membrane

 Normal skin temperature

 Normal skin sensation
 Skin elastic
 Adequate skin hydration
 Normal skin color
 Free of tissue lesions
 Intact skin (no erythema and necrosis)

NOC Labels >> Wound healing: primary intention

 No extension of wound edges

 There is no erythema in the area around the wound

INTERVENTION RATIONAL
NIC Labels >> Skin care: Topical 1. Evaluate the status of skin damage so
treatments that it can provide the right intervention.
1. Monitor the progress of client skin 2. Humid conditions can increase the
damage every day. proliferation of microorganisms and to
2. Prevent the use of coarse-textured prevent the occurrence of skin lesions
linens and keep the linen clean, not damp, caused by friction with linen.
and not tangled. 3. To improve the healing process of skin
4. Perform aseptic skin care twice a day. lesions and prevent secondary infection.
NIC Labels >> Wound care 1. Monitoring wound characteristics may
1. Monitor wound characteristics, assist the nurse in determining appropriate
including color, size, odor and discharge wound care and handling for the patient
on the wound 2. Normal saline is a physical fluid similar
2. Clean the wound with normal copy to body fluids so it is safe to use for
3. Apply a bandage to the wound cleaning and treating wounds.
according to the wound condition 3. Wound permtation is done to speed up
4. Maintain sterile techniques in wound the process of wound closure. Material
care of patients selection and dressing method adapted to
the type of wound patient.
4. Wound care while maintaining sterility
can prevent the patient from infection

Diagnose 4: Body image disturbance related to surgery

Goals: After getting treatment for 2 days the problem of body image is overcome

Results: After intervention for 2 X 24 problem of body image disorder can overcome
evaluation criteria

NOC label: Adaptation to Physical Disability

Able to adapt to functional limitations (scale 4 from 1 - 5)

NOC label: Body Image

Satisfied with body appearance (scale 4 from 1 - 5)

Be able to adjust to changes in body function (scale 4 from 1 - 5)

NOC Label: Self Esteem

Feel her worth (scale 4 from 1 - 5)

INTERVENTION RATIONAL
NIC label: Body Image Enhancement 1. To find out how much the client is able
1. Monitor the frequency of self-critical to accept his situation
sentences 2. To increase client confidence
2. Help clients to recognize actions that 3. To increase the confidence and spirit of
will improve their appearance the client
3. Facilitate client relationships with 4. To know the personal strength of the
individuals who experience similar body client
image changes
Identify group support available to clients
NIC label: Self Esteem Enhancement 1. In order for the client to know how
1. Encourage clients to assess their much his personal strength
personal strengths 2. In order for clients to be more confident
2. Encourage eye contact in 3. In order for the client can do the
communicating with others activity
3. Environmental facilitation and 4. Monitor the condition of the client
activities that will enhance the client's
self-esteem
4. Monitor the client's self-esteem level
from time to time appropriately
 REFERENCE

Hayes, Malcolm M. M. & Gia-Khanh Nguyen. 2014. Cytodiagnosis of Breast Lesions , An

Atlas and Text. Canada: Medical Journal. ISBN: 978-0-9881205-2-5

Marilyn A Roubidoux, MD. 2015. Breast Fibroadenoma Imaging.

https://emedicine.medscape.com/article/345779-overview. Accessed Jan. 23. 2018

Mayo Clinic Staff. 2017. Fibroadenoma, Diagnosis and Treatment.

https://www.mayoclinic.org/diseases-conditions/fibroadenoma/diagnosis-treatment/drc-
20352756. Accessed Jan. 23. 2018

Mayo Clinic Staff. 2017. Fibroadenoma, Symptomps and Causes.

https://www.mayoclinic.org/diseases-conditions/fibroadenoma/symptoms-causes/syc-
20352752. Accessed Jan. 23. 2018

A.D.A.M., Inc. 2017. Fibroadenoma – breast.

https://medlineplus.gov/ency/article/007216.htm. Accessed Jan. 23. 2018

Advisor CT Advisor CI

Zaqyyah Huzaifah, Ns, M.Kep Muhammad Ridha Rahmani, S.kep, Ns