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8/11/2019 Ductal Carcinoma Case Study
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OBJECTIVES
General:
The study aims to improve the knowledge of the students regarding on Ductal Carcinoma. It gives the
students the opportunity to learn different aspects regarding on the case of the patient. It broadens theunderstanding of the students regarding on the body system involves. It also makes the students see the reality of
what they are studying in lecture of Medical-Surgical Nursing subject.
The study also aims to apply the different skills that the students learned from their related learning
experiences regarding on physical assessment and also on those different nursing interventions that they must
apply to the patients situation.
Aside from the knowledge and skills that this study aims to enhance, it also encompasses the attitude
aspect of the students. Their approach to the patient is important for them to establish rapport; it gives them the
opportunity to build good and trusting relationship with the patient and gather more accurate information and
achieve possible health outcomes.
Specific:
1. To be aware on how this case affects persons and how prevalent this situation is.
2. To be skill-oriented on how to identify and to properly observe the status of this case in our present time.
3. To be well-communicated with the client during the physical assessment and interviews.
4. To enhance our learned skills on assessing the client and how to classify abnormalities with different
aspects such as physical, emotional, mental and spiritual.
5. To make ourselves oriented to different laboratory results and how we can relate it with the situation of
the client.
6. To enhance our knowledge in anatomy and physiology of the system involve.
7. To practice our skills in doing the pathophysiology of the case of the client.
8. To understand the drugs and its uses according to the clients situation.
9. To provide nursing care plan and discharge plan to assure clients total wellness.
10.
To know the proper attitude that an ideal nurse must possess.11. To learn how to make the proper approach to client to get their trust.
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I. INTRODUCTION
a. Background of the Study
I. Incidence, race, gender, age, ratio and proportion
The highest rates of breast cancer occur in Western countries (more than 100cases per 100,000 women) and the lowest among Asian countries (1015 cases per
100,000 women). Men can also have breast cancer, but the incidence is much less when
compared to women. There is a strong genetic correlation since breast cancer is more
prevalent in females who had a close relative (mother, sister, maternal aunt, or
maternal grandmother) with previous breast cancer. Increased susceptibility for
development of breast cancer can occur in females who never breastfed a baby, had a
child after age 30, started menstrual periods very early, or experienced menopause very
late.
In the United States, there were approximately 175,000 cases of breast cancer
in 1999 with more than 43,000 deaths. Breast cancer accounts for 30% of all cancer
diagnosed in American women and for 16% of all cancer deaths. Breast cancer is a
worldwide public health problem since there are approximately one million new cases
diagnosed annually. A woman's lifetime risk of developing breast cancer is one in eight.The incidence rose 21% from 1973 to 1990, but in recent years there has been a decline.
http://www.encyclopedia.com/doc/1G2-3406200301.html
II. Rationale for Choosing the case
Our Clinical Instructor decided to choose the case of Ductal Carcinoma because
this is common among women specially age 45years old and above. This case will help
us dig deeper on how and why it happens to those persons.
Also, the patients data is somehow complicated, such as her age and
background history, which is very interesting to find out if it is parallel to be the cause of
the case. It really make us wonder how it happens to a person and how will it bedistinguish.
III. Significance of the studies
The significance of the study is to enhance and of course to gain knowledge, to develop
skills and to apply the attitudes that must be render to the client whatever the case may
be. This study will also contribute in the widening of the ideas of the student about the
topic of the case.
These are other significance of the study that would support the above statement:
To be aware on how this case affects a person and how prevalent this situation
is. To be skill-oriented on how to identify and to properly observe the status of this
case in our present time.
To be well-communicated with the client during the physical assessment and
interviews.
To enhance our learned skills on assessing client and how to classify
abnormalities with different aspects such as physical, emotional, mental and
spiritual.
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To make ourselves oriented to different laboratory results and how we can relate
it with the situation of the client.
To enhance our knowledge in anatomy and physiology of the system involve.
To practice our skills in doing the pathophysiology of the case of the client.
To understand the drugs and its uses according to the clients situation.
To provide nursing care plan and discharge plan to assure clients total wellness.
To know the proper attitude that an ideal nurse must possess. To learn how to make the proper approach to client to get their trust.
IV. Scope and limitation of the study
The study would only focus on the information gathered from the patient, relatives of
the patient, from her records and laboratory results. This will be covering about the case
of Ductal Carcinoma, all about its anatomy and physiology and how did all of the records
may it be the medications, doctors order and nurses notes correlates to each other.
V. Conceptual Theoretical Theory
LYDIA HALLNURSING THEORY
(Core, Care, and Cure Model)
The Core. The core of human being is his/her needs to meet the Quality of Life (QOL). It is in
these needs that makeup and creates an individual.
The Care. The type of care a nurse will render in any case of altered health pattern can be in the
form of promotive, preventive, curative, rehabilitative and palliative aspects of care. Promotive care focus
on health promotion which is categorized with no source of health information, visits to well-
clinic/centers or oriented to health programs and practicing a healthy lifestyle and with good
environment.
The Cure. This identifies the level of care to be given to a person in case of altered healthpattern. Level 1 Cure covers promotive and preventive care are indications for primary health care
management. The major purposes of this level are to promote wellness and prevent illness or disability.
This level occurs at home or community and the participants in the care of geriatrics is the
private/family/community nurse, family and patients self that will emphasize the development of healthy
lifestyle and environment. Level 2, or early stage of curative phase, is an indication for secondary health
care management.
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VI.
Related Literature of the study
Invasive ductal carcinoma
Invasive ductal carcinoma (IDC), sometimes called infiltrating ductal carcinoma,
is the most common type of breast cancer. About 80% of all breast cancers are
invasive ductal carcinomas.Invasivemeans that the cancer has invaded or spread to the surrounding
breast tissues. Ductalmeans that the cancer began in the milk ducts, which are the
pipes that carry milk from the milk-producing lobules to the nipple. Carcinomarefers
to any cancer that begins in the skin or other tissues that cover internal organs
such as breast tissue. All together, invasive ductal carcinoma refers to cancer that
has broken through the wall of the milk duct and begun to invade the tissues of the
breast. Over time, invasive ductal carcinoma can spread to the lymph nodes and
possibly to other areas of the body.
According to the American Cancer Society, more than 180,000 women in the
United States find out they have invasive breast cancer each year. Most of them are
diagnosed with invasive ductal carcinoma.
Although invasive ductal carcinoma can affect women at any age, it is more
common as women grow older. According to the American Cancer Society, about two-thirds of women are 55 or older when they are diagnosed with an invasive breast
cancer. Invasive ductal carcinoma also affects men.
Symptoms
At first, invasive ductal carcinoma may not cause any symptoms. Often, an
abnormal area turns up on a screening mammogram (x-ray of the breast), which leads
to further testing.
In some cases, the first sign of invasive ductal carcinoma is a new lump or mass
in the breast that you or your doctor can feel. According to the American Cancer
Society, any of the following unusual changes in the breast can be a first sign of breast
cancer, including invasive ductal carcinoma:
swelling of all or part of the breast
skin irritation or dimpling
breast pain
nipple pain or the nipple turning inward
redness, scaliness, or thickening of the nipple or breast skin
a nipple discharge other than breast milk
a lump in the underarm area
Complications
Lead to premature death
Spread of cancer to other parts of the body
Prone
Female
Get older
Have a family history of breast cancer
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Diagnosis
Diagnosing invasive ductal carcinoma usually involves a combination of procedures, including
a physical examination and imaging tests.
Physical examination of the breasts: The doctor may be able to feel a small lump in thebreast during a physical examination. He or she also will feel the lymph nodes under the
armpit and above the collarbone to see if there is any swelling or other unusual changes.
Mammography:Invasive ductal carcinoma is usually found by mammography, a test
that obtains x-ray images of the breast. Mammograms are used to screen apparently healthy
women for early signs of breast cancer. One key feature of an invasive breast cancer is
spiculated margins, which means that on the mammography film, the doctor sees an
abnormality with finger-like projections coming out of it. These projections show the
invasion of the cancer into other tissues.
If a screening mammogram highlights an area of concern, additional mammograms often will
be done to gather more information about that area. Mammography will be performed on
both breasts.
Ultrasoundbounces sound waves off of the breast to obtain additional images of the
tissue. Ultrasound is sometimes used in addition to mammography.
Breast MRI:MRI, or magnetic resonance imaging, uses magnetic fields, radio waves, and
a computer to obtain images of tissues inside the body. In certain cases, a doctor may use
breast MRI to gather more information about a suspicious area within the breast.
Biopsy:If you do have a suspicious mammogram or other imaging test result, your
doctor will probably want you to have a biopsy. A biopsy involves taking out some or all of
the abnormal-looking tissue for examination by a pathologist (a doctor trained to diagnose
cancer from biopsy samples) under a microscope.
When possible, your doctor will usually use one of the quicker, less invasive approaches to
biopsy:
o Fine needle aspirationbiopsy involves inserting a very small, hollow needle into the
breast. A sample of cells is removed and examined under the microscope. This method leaves
no scars.o Core needle biopsyinserts a larger needle into the breast to remove several cylinder-
shaped samples of tissue from the area that looks suspicious. In order to get the core needle
through the skin, the surgeon must make a tiny incision. This leaves a very tiny scar that is
barely visible after a few weeks.
In cases where the doctor cannot feel the lump, he or she may need to use ultrasound or
mammograms to guide the needle to the right location. You may hear this referred to as
stereotactic needle biopsy or ultrasound-guided biopsy.
If a needle biopsy is not able to remove cells or tissue, or it does not give definite results
(inconclusive), a more involved biopsy may be necessary. These biopsies are more like
regular surgery than needle biopsies:
o Incisional biopsyremoves a small piece of tissue for examination.
o Excisional biopsyattempts to remove the entire suspicious lump of tissue from the
breast.Again, if the doctor cannot feel the lump, he or she may need to use mammography or
ultrasound to find the right spot. Your doctor also may use a procedure called needle wire
localization. Guided by either mammography or ultrasound, the doctor inserts a small hollow
needle through the breast skin into the abnormal area. A small wire is placed through the
needle and into the area of concern. Then the needle is removed. The doctor can use the
wire as a guide in finding the right spot for biopsy.
These surgical biopsies are done only to make the diagnosis. If invasive ductal carcinoma is
diagnosed, more surgery is needed to ensure all of the cancer is removed along with clear
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margins, which means that a border of healthy tissue around the cancer is also removed.
Usually this means having lumpectomy, or in some cases, mastectomy.
Treatment
Treatment options may include:
Axillary lymph node dissection
Chemotherapy
Lumpectomy
Mastectomy
Radiation therapy
Selective Estrogen Receptor
Modulator
Sentinel Node Biopsy
Targeted Therapy
Lifestyle Changes
Massage
Meditation
Music therapy
Hypnosis
Relaxation techniques, such as guided imagery
Tai chi
Yoga
Medications
The drug tamoxifenblocks the action of estrogen a hormone that fuels some breastcancer cells and promotes tumor growth to reduce your risk of developing invasive breast
cancer. Tamoxifen is effective only against cancers that grow in response to hormones (hormone
receptor positive cancers).Tamoxifen isn't a treatment for DCIS in and of itself, but it can be
considered as additional (adjuvant) therapy after surgery or radiation in an attempt to decrease
your chance of developing a recurrence of DCIS or invasive breast cancer in either breast in the
future.
Nursing Intervention
1. Support the patient emotionally and offer reassurance.
2.
Administer prescribed medications.3. Provide six small meals a day or small hourly meals as ordered.
4. Schedule care so that the patient gets plenty of rest.
5. Monitor the effectiveness of administered medications, and also watch
for adverse reactions.
6. Assess the patients nutritional status and the effectiveness of measures
used to maintain it. Weigh him regularly.
7. Teach the patient about peptic ulcer disease, and help him to recognize
its signs and symptoms.
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8. Review the proper use of prescribed medications, dicussing the desired
actions and possible adverse effect of each drug.
9. Instruct the patient to take antacids 1 hour after meals.
10. Warn the patient to avoid aspirin containing drugs because they irritate
gastric mucosa.
11. Encourage the patient to make appropriate lifestyle changes.
II. CLINICAL SUMMARY
A. General Data Profile
NAME: Mrs. VAP
ADDRESS: Brgy. Mapagong, Pagbilao,Quezon
AGE: 50y/o
WEIGHT: 69kg
HEIGHT: 411 ft.
BIRTHDAY: Dec. 10, 1963
BIRTHPLACE: Masbate
SPOUSE: Mr. EX
NATIONALITY: Filipino
RELIGION: Roman Catholic
OCCUPATION: House Wife
DATE OF ADMISSION: August. 13, 2013
ADMITTING DIAGNOSIS: Breast Mass Left, Excision Biopsy
ADMITTING PHYSICIAN: Dr. Durbin William Jeffrey N. Tang
B. CHIEF COMPLAINT
-With Mass on the Left Breast for 5 years
C. Nursing History
a.
Childhood Illnesses- Common colds, cough and fever
b. Immunizations
- BCG ( 7yrs/old)
c. Allergies
- No allergy at all.
d. Accidents
-The client had no known accident.
e. Hospitalizations
-Quezon Medical Center year 2001 due to delivery of the baby via Ceasarian section
f. Medications used or currently taking
- Mefenamic if he feels pain and Herbal meds
g. Domestic Travel
-
She is traveling from Palawan, Masbate and Quezon Province to visit her relatives.
D. Health History
A. Medical History
a. Chronic Illness
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- The client is experiencing from Urinary Tract Infection
b.
Current Medications
Drug Dose Route Time
Atracarium 25mg IV
Propofol 80mg + 30mg IV
Butorphanol 1mg IV
Neostigmine +
Atropine Sulfate
5mg + 1mg
respectively
IV
Cefuroxime 750mg IV Every 8 hours
Keterolac 30mg IV Every 6 hours
Tramadol 50mg IV Every 4 hours
Paracetamol 300mg IV Every 4 hours
Cefuroxime 500mg Oral tab Three times a day
Celecoxib 200mg Oral tab Two times a day
c. Childhood Illness
-
Common colds, cough and feverB. Surgical History
a. Problems with anesthesia
- The client stated that she has no problem with anesthesia nor allergies with it.
b. Previous Surgeries
- The client had undergo to surgery at year 2001 due to her delivery to her baby via
Cesarean Section
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E. FAMILY HISTORY
Legend:
Male Male Death
Female Female Death
Patient
Prostitis T B
A&W A&W Tumor on A&W A&W
The colon
A&W A&
A&W Patient
A&W A&W
Mass on
Breast
89 65
12
20
17
18
21
48
12
58
61
15
19
24
70
25 5
50
17
49
17
51
3917
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F. SOCIAL HISTORYINCLUDE THEORIES AND GROWTH AND DEVELOPMENT
PSYCHOSOCIAL THEORY ACCORDING TO ERIK ERIKSON
STAGE AGE CENTRAL TASK INDICATORS OF POSITIVE
RESOLUTION
INDICATORS OF
NEGATIVE RESOLUTION
Adulthood 25-65years
Generativityversus
stagnation
Creativity,productivity,
concern for
other s
Self-indulgence,lack of interests
and
commitments.
According to this theory adulthood had creativity, productivity, concern for other. Based
on what the client said she wanted to sustain the need of her family especially her children future
and education, in spite of her of present condition.
ACCORDING TO SIGMUND FREUD
PSYCHOSEXUALTHEORY
STAGE AGE CHARACTERISTICS IMPLICATION
Genital Puberty and after Energy is directed
toward full sexual
maturity and function
and development of
skills needed to cope
with the environment
Encourages separation
from parents,
achievement of
independence and
decision making
According to this theory, the genital stage correlates to her age because she gains
independence in decision making to do normal things. Though she experiences pain physically due
to her condition it was only now that she experiences it that affected her sexual maturity and
function and development of skills.
G.
ENVIRONMENTAL/ LIVING CONDITION
The environment where they live and work is along a roadside. There are tricycle and
jeep which can be means of transportation. The type of their house not completely cemented,
but is well ventilated.
H. PHYSICAL ASSESSMENT PHYSICAL ASSESSMENT
Date of Assessment: August. 14, 2013
General Appearance: Pre-Operative
The patient is alert, conscious and coherent. She is in line with her biological and apparent age. She wears
blouse and shorts exactly for her body. Upon assessment, the client is lying on bed.
BODY PART NORMAL FINDINGS ACTUAL FINDINGSINTERPRETATION/ ANALYSIS
A. HEAD
1. SKULLProportional to the size
of the body, round, with
prominences in the
frontal area anteriorly
Proportional to the
size of the body,
symmetrical in all
Normal.
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and the occipital area
posteriorly symmetrical
in all planes.
planes.
2. SCALP White, clean, free from
masses, lumps, scars,
nits, dandruff, and lesion
White, clean, free
from masses, lumps,
scars, nits, and lesions
Normal
3. HAIR Black or whitish, evenly
distributed and covers
the whole scalp, thick,
shiny, free from split
ends.
Black hair; evenly
distributed, thin,
bristle-like and coarse.
Normal
4. FACE Oblong/oval/square or
heart-shaped,
symmetrical, facial
expressions that is
dependent on the mood
or true feelings, smooth
and free from wrinkles,no involuntary muscle
movements.
Oval shape.
Symmetrical, free
from wrinkles and
scars. No involuntary
muscle movements.
Normal.
B. EYES
1.EYEBROWS Black, symmetrical,
thick, can raise and
lower eyebrows
symmetrically and
without difficulty, evenly
distributed and parallel
with each other.
Black, symmetrical.
Thin. Can raise and
lower eyebrows.
Normal
2. EYELIDS Upper lids cover a small
portion of the iris,
cornea, and the sclera
when the eyes are open.
When the eyes are
closed, the lids meet
completely. Symmetrical
color is the same as the
surrounding skin.
Upper lids cover a
small portion of the
iris, cornea, and the
sclera when the eyes
are open. When the
eyes are closed, the
lids meet completely.
Same color of
surrounding skin.
Normal
3. LID MARGINS
4. CONJUNCTIVA
Clear, without scaling or
secretions, lacrimal duct
openings are evident at
the nasal ends.
Pink, without lesions
Clear, without scaling
or secretions
Pink without lesions
Normal
Normal
5. SCLERA White and clear. White and clear. Normal
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6. IRIS Proportional to the size
of the eye, round,
black/brown, and
symmetrical.
It is symmetrical,
round and
proportional to size.
Normal
7. PUPIL From pinpoint to almost
the size of the iris,
round, symmetrical,constrict with increasing
light and
accommodation.
Symmetrical
constricted to light
and accommodatedfrom light.
Normal
8. CORNEA Clear Clear Normal
9. EYE MOVEMENT Able to move eyes in full
range of motion or able
to move in all directions.
Able to move eyes in
six field of gaze.
Normal
C. EARS Pinkish, clean, with scant
amount of cerumen and
a few cilia.
Cerumen and a few
cilia.
Normal
1. HEARING ACUITY Able to hear whisper
spoken words 2 feet
away.
Able to hear whisper
spoken words 2 feet
away.
Normal
2. EAR CANAL No erythema, no scaling,
no swelling, absence of
foreign body and odor.
No erythema, no
scaling, absence of
foreign body and
odor.
Normal
D. NOSE Midline, symmetrical,
and patent.
Midline, symmetrical,
and patent.
Normal
1. INTERNAL NARES Clean, pinkish, with few
cilia.
Clean, pinkish, with
few cilia.
Normal
2. SEPTUM Straight. Straight. NormalE. MOUTH Pinkish, symmetrical lip
margin, well-defined,
smooth and moist.
Pinkish, symmetrical,
lip margin, well-
defined, smooth and
moist.
Normal
1. LIPS Pinkish, smooth, moist,
no swelling, no
retraction, no discharge.
Pinkish lips. No
swelling.
Normal
2. TEETH 28-32 permanent teeth,
well-aligned free from
caries or filling, no
Halitosis.
28-32 permanent
teeth, well-aligned
free from caries or
filling, no Halitosis.
Normal
3. TONGUE Large, medium, red or
pink, the lateral margins,
moist, shiny, and freely
Movable.
Medium, red, the
lateral margins, moist,
shiny, and freely
movable.
Normal
4. CHEEKS
(BUCCAL MUCOSA)
Pinkish, moist. Pinkish, moist. Normal
5. PALATE Pinkish, moist, and Moist, and smooth. Normal
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lesions and edema. for 5 years with
wound on the left
breast.
under Modified Radical Mastectomy.
L. UPPER
EXTREMITIES1. ARMS
Inspection Skin varies (pinkish, tan,
dark brown), skin is
smooth, fine hair evenly
distributed, muscles
symmetrical, length
symmetrical.
Tan skin muscle,
length symmetrical,
fine hair evenly
distributed.
Normal
Palpation Warm, dry and elastic,
no areas of tenderness.
Muscle appears equal
with good muscle tone.
Warm, dry and no
areas of tenderness.
Normal
M. NAILS Nails are transparent,smooth, & convex with
pink nail beds & white
translucent tips.
Five fingers in each
hand. As pressure is
applied to the nail bed,
it appears white or
blanched & pink color
returns immediately as
pressure is released.
Complete fingers, 5each hand.
Nails are short, thick,
transparent, & convex
with pale nail beds &
white translucent tips.
As pressure is applied
to the nailbed, it
appears white and
color returns after 2
seconds.
Normal
N. SHOULDERS,
ARMS, ELBOWS,
HANDS & WRISTS
ABDUCTION AND
ADDUCTION.
Performs with relative
ease.
Physical mobility of
the upper extrimities
is slightly impaired,
especially on the left
side.
Due to pain associated with the presence
of surgical incision on the left breast.
O. LOWER
EXTREMITIES
1. LEGS
Inspection Skin varies (pinkish, tan,
dark brown), skin is
smooth, fine hair evenly
distributed, absence of
varicose veins, muscles
symmetrical, lengthsymmetrical.
Skin is uniformed in
tan color Hair evenly
distributed.
Normal
Palpation Muscles appear equal,
warm & with good
muscle tone.
Muscles appear equal,
warm & with good
muscle tone.
Normal
2. TOES
InspectionFive toes in each foot: Five toes in each foot.
Normal
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sole and dorsal surface
is smooth: With pink nail
beds & translucent tips.
Sole and dorsal
surface is smooth
Palpation As pressure is applied,
the nail beds appear
white or blanched; pink
color returns whenpressure is released (2
seconds).
As pressured is
applied to nail beds,
color becomes white,
colors returns afterless than 2 seconds
Normal
P. LEGS, KNEES,
ANKLES, TOES
ADDUCTION AND
ABDUCTION.
Performs with relative
ease.
Performs with relative
ease.
Normal
Date of Assessment: August. 15, 2013
General Appearance: Post-Operation
The patient is alert, conscious and coherent. She is in line with her biological and apparent age. She wears
blouse and shorts exactly for her body. Upon assessment, the client is lying on bed, with a blood pressure of
120/80 mmHg, pulse rate of 79 beats per minute, respiration rate of 17 breaths per minute, and temperature of
38.9 C.
BODY PART NORMAL FINDINGS ACTUAL FINDINGSINTERPRETATION/ ANALYSIS
A. HEAD
1. SKULLProportional to the size
of the body, round, with
prominences in the
frontal area anteriorly
and the occipital area
posteriorly symmetrical
in all planes.
Proportional to the
size of the body,
symmetrical in all
planes.
Normal.
2. SCALP White, clean, free from
masses, lumps, scars,
nits, dandruff, and lesion
White, clean, free
from masses, lumps,
scars, nits, and lesions
Normal
3. HAIR Black or whitish, evenly
distributed and covers
the whole scalp, thick,
shiny, free from split
ends.
Black hair; evenly
distributed, thin,
bristle-like and coarse.
Normal
4. FACE Oblong/oval/square or
heart-shaped,symmetrical, facial
expressions that is
dependent on the mood
or true feelings, smooth
and free from wrinkles,
no involuntary muscle
movements.
Oval shape.
Symmetrical, freefrom wrinkles and
scars. No involuntary
muscle movements.
Normal.
B. EYES
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1.EYEBROWS Black, symmetrical,
thick, can raise and
lower eyebrows
symmetrically and
without difficulty, evenlydistributed and parallel
with each other.
Black, symmetrical.
Thin. Can raise and
lower eyebrows.
Normal
2. EYELIDS Upper lids cover a small
portion of the iris,
cornea, and the sclera
when the eyes are open.
When the eyes are
closed, the lids meet
completely. Symmetrical
color is the same as the
surrounding skin.
Upper lids cover a
small portion of the
iris, cornea, and the
sclera when the eyes
are open. When the
eyes are closed, the
lids meet completely.
Same color of
surrounding skin.
Normal
3. LID MARGINS
4. CONJUNCTIVA
Clear, without scaling or
secretions, lacrimal duct
openings are evident at
the nasal ends.
Pink, without lesions
Clear, without scaling
or secretions
Pink without lesions
Normal
Normal
5. SCLERA White and clear. White and clear. Normal
6. IRIS Proportional to the size
of the eye, round,black/brown, and
symmetrical.
It is symmetrical,
round andproportional to size.
Normal
7. PUPIL From pinpoint to almost
the size of the iris,
round, symmetrical,
constrict with increasing
light and
accommodation.
Symmetrical
constricted to light
and accommodated
from light.
Normal
8. CORNEA Clear Clear Normal
9. EYE MOVEMENT Able to move eyes in full
range of motion or able
to move in all directions.
Able to move eyes in
six field of gaze.
Normal
C. EARS Pinkish, clean, with scant
amount of cerumen and
a few cilia.
Cerumen and a few
cilia.
Normal
1. HEARING ACUITY Able to hear whisper
spoken words 2 feet
away.
Able to hear whisper
spoken words 2 feet
away.
Normal
2. EAR CANAL No erythema, no scaling, No erythema, no Normal
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no swelling, absence of
foreign body and odor.
scaling, absence of
foreign body and
odor.
D. NOSE Midline, symmetrical,
and patent.
Midline, symmetrical,
and patent.
Normal
1. INTERNAL NARES Clean, pinkish, with fewcilia.
Clean, pinkish, withfew cilia.
Normal
2. SEPTUM Straight. Straight. Normal
E. MOUTH Pinkish, symmetrical lip
margin, well-defined,
smooth and moist.
Pinkish, symmetrical,
lip margin, well-
defined, smooth and
moist.
Normal
1. LIPS Pinkish, smooth, moist,
no swelling, no
retraction, no discharge.
Pinkish lips. No
swelling.
Normal
2. TEETH 28-32 permanent teeth,
well-aligned free fromcaries or filling, no
Halitosis.
28-32 permanent
teeth, well-alignedfree from caries or
filling, no Halitosis.
Normal
3. TONGUE Large, medium, red or
pink, the lateral margins,
moist, shiny, and freely
Movable.
Medium, red, the
lateral margins, moist,
shiny, and freely
movable.
Normal
4. CHEEKS
(BUCCAL MUCOSA)
Pinkish, moist. Pinkish, moist. Normal
5. PALATE
SOFT PALATE
HARD PALATE
Pinkish, moist, and
smooth.
Slightly pinkish.
Moist, and smooth.
Slightly pinkish.
Normal
Normal
6. UVULA At the center,
symmetrical, and freely
movable.
At the center,
symmetrical, and
freely movable.
Normal
7. TONSILS Pinkish, non-inflamed,
no exudates.
Pinkish, non-inflamed,
no exudates.
Normal
8. VOICE No hoarseness and well-
modulated.
No hoarseness and
well-modulated.
Normal
F. NECK Proportional to the size
of the body and head,
symmetrical and
straight.
Proportional to the
size of the body and
head, symmetrical and
straight.
Normal
G. RANGE OFMOTION
Freely movable withrelative ease.
Limited range ofmotion especially on
the left side of the
body
Due to presence of the surgical incisionon the left breast.
H. MUSCULAR
STRENGTH
Symmetrical movements
and able to resist force
applied by the nurse.
Able to resist force
applied only at the
right side of the body.
Due to presence of the surgical incision
on the left breast
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I. HEART Regular beats
(60-100 beats per
minute).
Regular beats (79
beats per minute)
Normal
J. ABDOMEN
Inspection
1. Abdomen skin
2. Contour and
Symmetry
3. Movements
associated w/
respiration
Unblemished skin;uniform color.
Flat, rounded;
symmetric contour.
Symmetric movements
caused by respiration.
With scar caused bysurgical incision via CS.
Rise and fall caused by
respiration.
Due to the delivery of her baby via CS.
Normal
Auscultation Audible bowel sounds
(5-30/min); absence of
arterial bruits and
friction rubs.
Audible bowel sounds
(10/min).
Normal
Palpation No tenderness; relaxed
abdomen with smooth,
consistent tension.
No area of
tenderness; no
presence of lumps and
masses absence of
lesion.
Normal
K. CHEST (THORAX)
Inspection Chest symmetrical, skin
intact, no tenderness, no
masses.
Chest symmetrical. No
lumps, tenderness and
masses.
Respiration of 17
breaths per minute
Normal
Breast The breast has no
lesions and edema.
With presence of
surgical incision on
left breast. The right
breast has no lesions
and edema.
Due to removal of the mass on the left
breast.
L. UPPER
EXTREMITIES
1. ARMSInspection Skin varies (pinkish, tan,
dark brown), skin is
smooth, fine hair evenly
distributed, muscles
symmetrical, length
symmetrical.
Tan skin muscle,
length symmetrical,
fine hair evenly
distributed.
Normal
Palpation Warm, dry and elastic,
no areas of tenderness.
Warm, dry and no Normal
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Muscle appears equal
with good muscle tone.
areas of tenderness.
M. NAILS Nails are transparent,
smooth, & convex with
pink nail beds & whitetranslucent tips.
Five fingers in each
hand. As pressure is
applied to the nail bed,
it appears white or
blanched & pink color
returns immediately as
pressure is released.
Complete fingers, 5
each hand.
Nails are short, thick,transparent, & convex
with pale nail beds &
white translucent tips.
As pressure is applied
to the nailbed, it
appears white and
color returns after 2
seconds.
N. SHOULDERS,
ARMS, ELBOWS,
HANDS & WRISTS
ABDUCTION ANDADDUCTION.
Performs with relative
ease.
Physical mobility of
the upper extrimities
is slightly impaired,
especially on the leftside.
Due to pain associated with the presence
of surgical incision on the left breast.
O. LOWER
EXTREMITIES
1. LEGS
Inspection Skin varies (pinkish, tan,
dark brown), skin is
smooth, fine hair evenly
distributed, absence of
varicose veins, muscles
symmetrical, length
symmetrical.
Skin is uniformed in
tan color Hair evenly
distributed.
Normal
Palpation Muscles appear equal,
warm & with good
muscle tone.
Muscles appear equal,
warm & with good
muscle tone.
Normal
2. TOES
InspectionFive toes in each foot:
sole and dorsal surface
is smooth: With pink nail
beds & translucent tips.
Five toes in each foot.
Sole and dorsal
surface is smooth
Normal
Palpation As pressure is applied,
the nail beds appear
white or blanched; pink
color returns whenpressure is released (2
seconds).
As pressured is
applied to nail beds,
color becomes white,
colors returns afterless than 2 seconds
Normal
P. LEGS, KNEES,
ANKLES, TOES
ADDUCTION AND
ABDUCTION.
Performs with relative
ease.
Performs with relative
ease.
Normal
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I. PATTERNS OF FUNCTIONING
Functional Health
Pattern
Before
Hospitalization
During
Hospitalization
(after operation)
Interpretation
Health management
pattern
She is taking
analgesics if she
feels pain and herbal
meds.
The client is
dependent on what
the physician has
ordered her to do.
She takes OTC drugs
whenever she feels
something and
herbal meds as what
the elders has told
her.
Nutritional/ Metabolic
Pattern
- Number of meals
per day
- Appetite
- Glass of water per
day
- Body Built
- Height and weight
3 times a day
w/ very good
appetite
6 glasses of water
w/ normal body built
411 and 69 kg
NPO
With normal body
built
Her number of meals
is now deprived
because it is needed
in preparation for
her pre and post
operation.
Elimination
- Frequency of
urination
- Amount of urine
per day
- Frequency of bowel
- Consistency of feces
- Amount defecated
6 times a day
moderate
2
Formed
Moderate
2 times a day
Moderate
1
Formed
scanty
Her frequency of
urination and
defecation isdeprived because
she is placed on NPO
and IVF acts as her
food.
Activity and Exercise
- Exercise
- Fatigability
- ADL
Daily walking
Easily get tired
Independent
Unable to performed
exercise
Easily get tired
Slightly dependent
She considers
walking as her daily
exercise but when
she is hospitalized
she became slightly
dependent and
unable to performed
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her daily activities.
Cognitive/ Perceptual
- Orientation
-
Responsiveness
Oriented to time
place and person
Respondapproximately to
verbal and physical
stimuli.
Oriented to time,
place and person
Respondapproximately to
verbal and physical
stimuli.
She is well oriented
and can respond to
verbal and physical
stimuli.
Roles/ Relationship
- As a daughter
- As a sister
- As a wife
- As a mother
She has a good
relationship with her
parents
She has good
relationship with her
siblings.
she has good
relationship with her
husband, they enjoy
their lives together
She has good
relationship with her
children; she cares
for them a lot.
Her parents always
supported her when
they were still alive.
Shes supported by
her siblings during
her hospitalization.
Her husband really
do support her and
settle all the things
for her during her
hospitalization
She always takes
care of her children
and supports them
with their needs.
There are good
relationship
between the family
members.
Self Perception and
concept
Have a high self
worth/ importance
Have a high self
worth/ importance
In spite of her
present condition,
she still has a high
self worth and
importance.
Coping/ Stress She seeks advice
from her husband,
and even sometimes
with her friends,
relatives and also
She trusts God for
she knows that
everything will turn
right when hes
there.
She wholly gives her
full trust to God
when shes inside
the hospital for she
knows that
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with God. everything is about
His will.
Values/ Belief Shes aware and she
trust God and believe
that He did exist.
Her trust to God
boosted more and
more confident
whenever praying.
she really did trust
God ever than the
way she trust Him
before.
J. COURSE IN THE WARD
DATEDOCTORS ORDERS
RATIONALE
August 13, 2013
10:35am
Please admit to Female Surgery Ward
Secure Consent
TPR
NPO
CBC
Blood Typing
Urine Analysis
IVF D5LR x 8hrs
Cefuroxime 750mg IV q8 ANST
For MRM (Modified Radical Mastectomy)
Left tomorrow
In preparation for surgical
procedure
To properly have consent
from the relatives of the
patient.
To monitor if there is
deviation from normal with
regards to the temperature,pulse and respiration of the
patient.
To prepare the patient for
the surgical procedure and to
depress the GI tract.
To monitor if there is any
deviation from normal values
of the components of blood
of the patient.
To know the blood type ofthe patient so that if ever
blood transfusion will be
done, the blood to be
administered has the same
type.
To know if the patient has
any disorder regarding to her
kidney or Urinary tract.
D5LR is parenteral fluid,
electrolyte and nutrient
replenisher It fights against bacteria
during infection.
MRM is for those patient
who has mass on their breast
and diagnosed to be
removed.
To refer if something urgent
happened to the patient.
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5:00pm
Refer OR/ AROD/ SROD
Refer Accordingly
Prepare 1 u FWB (Fresh Whole Blood)
properly typed and crossed match
NPO post midnight
Discontinue present IVF
IVF of D5LR 1L to be inserted at 5am
Refer to Dr. Encanto
Refer what has been
ordered.
To be ready if ever, during
the surgical procedure, the
patient loss lots of blood.
To make the patients GI
tract depress for the surgical
procedure to be done.
To give way for the
procedure to be done.
To get ready for the
procedure.
To endorse to the doctor
who will handle the patient.
August 14, 2013
9:25am
Post OR order
DAT when fully awake
Monitor VS every 10 mins for 6hrs, then
every 15 mins until stable.
IVF D5LR1L x 8hrs
IVF D5LR 1L x 8hrs
Cefuroxime 750mg IV q8
Keterolac 30mg IV q6/amp x 4doses ANST
Oxygen inhalaton 2-3L
Refer accordingly
Tramadol 50mg IV q4
For the patient easy
recovery. DAT will be
administered when fully
awake and not during
unconscious state to avoid
the occurrence of aspiration.
To monitor the adaptation of
the patient to the procedure
and if there are any deviation
from normal value of thepatients TPR, BP.
D5LR is parenteral fluid,
electrolyte and nutrient
replenisher
It fights against bacteria
during infection
It is for relief from pain due
to surgical procedure
To support the Oxygen
inhalation of the patient
Refer what has been
ordered.
Given for pain relief due to
surgical procedure.
August 15, 2013 Continue Medications It is being continued because
the prescribed one can
develop a resistance to
antibiotics if they are used
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10:00am
To follow D5LR x KVO
Paracetamol 30mg prn
appropriately which can
make it even more difficult to
treat the client next time and
also it being continue for
faster recovery and treat for
the prevention of the
disease. D5LR is parenteral fluid,
electrolyte and nutrient
replenisher
For the sudden increased in
temperature of the client.
August 16, 2013
DAT
IVF PNSS 1L x KVO
For repeat Hemoglobin and Hematocrit
Cefuroxime 500mg TID
Celecoxib 200mg BID
Add supplemex KVO
For the patient to eat what
the stomach can tolerate and
to return to normal function
of the GI tract.
Normal Saline is a sterile,
nonpyrogenic solution for
fluid and electrolyte
replenishment.
To check if the patient has
normal value of Hemoglobin
and Hematocrit after the
surgical procedure.
It fights against bacteria
during infection.
Use to treat pain
Supplement in IV form in
support for the recovery of
the patient.
August 17, 2013
Facilitate Bed rest
IVF same rate
Continue medications
Refer
Hgb = 7.4
Prepare and transfer 3 u Fresh Whole
Blood
To promote rest for the clientand blood circulation.
For same way of treatment.
For continuous treatment
and recovery of the patient.
To be refer accordingly due
to decreased Hgb.
There is a decreased from
the normal value (12-16 g/dl)
of patients Hemoglobin.
Since there is a decrease in
patients hemoglobin, she
needs to have blood
transfusion.
To check if there are any
changes and progress with
the patients hemoglobin and
hematocrit value.
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Repeat Hemoglobin and Hematrocrit 6hrs
post bedrest
August 18, 2013 MGH
Home meds as ordered
Follow up check up on
August 23, 2013 8am at OPD. For continuous adherence to
medication regimen.
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K. LABORATORY RESULTS:
DATE: August 13, 2013
REFERRENCE: essentials of anatomy and physiology sixth edition (Seeley, Stephens, Tate)
Name of test INDICATION Normal range Results Significance of the result
HEMOGLOBIN
HEMATOCRIT
WBC COUNT
-Neutrophils
-Lymphocytes
-Monocytes
-Eosinophil
-Basophil
PLATELET COUNT
CLOTTING TIME
BLEEDING TIME
Blood test can be used to
find out what is
happening in many parts
of the body. Testingblood is easier than
obtaining a tissue sample.
Any test designed to
discover abnormalities in
a sample of blood to
determine blood groups
(Merck Manual of
Medical information p.
888)
M:14-18 gm/dl
F:12-15 gm/dl
M:40-50%
F:30-40%
5,000-10,000
40%-50%
35%-45%
2%-5%
2-4%
0-1%
150,000-450,000
11.1
35.9
11,700
71%
29.7%
100%
Values decrease in anemia, hyperthyroidism, cirrhosis of the
liver and severe hemorrhage.
NORMAL
Values increase in acute infections, trauma, some malignant
disease, and some cardiovascular disease
Neutrophils increase in acute infections.
Lymphocytes increase during antigen-antibody reactions.
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Name of test INDICATION Normal range Results Significance of the result
HEMOGLOBIN
HEMATOCRIT
WBC COUNT
-Neutrophils
-Lymphocytes
-Monocytes
-Eosinophil
-Basophil
PLATELET COUNT
CLOTTING TIME
BLEEDING TIME
Blood test can be used to
find out what is
happening in many parts
of the body. Testing
blood is easier than
obtaining a tissue sample.
Any test designed to
discover abnormalities in
a sample of blood to
determine blood groups
(Merck Manual of
Medical information p.
888)
M:14-18 gm/dl
F:12-15 gm/dl
M:40-50%
F:30-40%
5,000-10,000
40%-50%
35%-45%
2%-5%
2-4%
0-1%
150,000-450,000
9.7
29
11,600
69%
31%
261,000
Values decrease in anemia, hyperthyroidism, cirrhosis of the
liver and severe hemorrhage.
Values decrease in anemia, leukemia, cirrhosis and
hyperthyroidism.
Values increase in acute infections, trauma, some malignant
disease, and some cardiovascular disease
Neutrophils increase in acute infections.
NORMAL.
NORMAL
REFERRENCE: essentials of anatomy and physiology sixth edition (Seeley, Stephens, Tate)
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DATE: August 16, 2013
REFERRENCE: essentials of anatomy and physiology sixth edition (Seeley, Stephens, Tate)
Name of test INDICATION Normal range Results Significance of the result
HEMOGLOBIN
HEMATOCRIT
RBC COUNT
MCV
MCH
MCHC
WBC COUNT
PLATELET COUNT
CLOTTING TIME
BLEEDING TIME
Blood test can be used to
find out what is
happening in many parts
of the body. Testing
blood is easier than
obtaining a tissue sample.
Any test designed to
discover abnormalities in
a sample of blood to
determine blood groups
(Merck Manual of
Medical information p.
888)
12.0-16.0
0.37-0.43
4.0-5.4
78-102
39.0-54.0
481-574
4.0-10.0
170-400
7.40
0.23
Values decrease in anemia, hyperthyroidism, cirrhosis of the
liver and severe hemorrhage.
Values decrease in anemia, leukemia, cirrhosis and
hyperthyroidism.
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DATE: August 16, 2013
BLOOD TYPING AND CROSSMATCHING RESULTS
PATIENTS ABOGROUP: O RH GROUP: positive
Source
of
blood
Donor
number
ABO
group
RH typing Interpretation Released
by:
Taken by Date and
time
QMC 1390-13 O Positive Saline phase
LISS/coombs-
37C
COMPATIBLE
Autocontrol Negative for agglutination
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Diagnosis:
Breast mass, left, excision biopsy
INVASIVE DUCTAL CARCINOMA, NUCLEAR GRADE 2, HISTOLOGIC GRADE 2
POSITIVE FOR LYMPHOVASCULAR AND PERIVASCULAR INVASION.
INVASIVE DUCTAL CARCINOMA, NUCLEAR GRADE 2, HISTOLOGIC GRADE 2
INVASIVE DUCTAL CARCINOMA
Invasivemeans that the cancer has invaded or spread to the surrounding breast tissues.Ductalmeans that the cancer began in the
milk ducts, which are the pipes that carry milk from the milk-producing lobules to the nipple. Carcinomarefers to any cancer that
begins in the skin or other tissues that cover internal organs such as breast tissue. All together, invasive ductal carcinoma refersto cancer that has broken through the wall of the milk duct and begun to invade the tissues of the breast. Over time, invasive ductal
carcinoma can spread to the lymph nodes and possibly to other areas of the body.http://pathology.jhu.edu/breast/grade.php
Grade I or low-grade DCIS cells look very similar to normal cells or atypical ductal hyperplasia cells. Grade II or moderate-grade DCIS cells grow faster than
normal cells and look less like them. Grade I and Grade II DCIS tend to grow slowly and are sometimes described as "non-comedo" DCIS. The term non-comedo
means that there are not many dead cancer cells in the tumor. This shows that the cancer is growing slowly, because there is enough nourishment to feed all
of the cells. When a tumor grows quickly, some of its cells begin to die off.
http://www.breastcancer.org/symptoms/types/dcis/diagnosis
=POSITIVE FOR LYMPHOVASCULAR AND PERIVASCULAR INVASION.
When LVI is present, doctors assume this means that the cancer has acquired the genetic mutation it needs to create its own blood vessels, a process called
angiogenesis. Because a tumor that has the ability to create its own blood vessels may have already begun to spread cancer cells to other parts of the body, the
presence of LVI is an indicator that treatment should most likely include chemotherapy or hormone therapy (if the tumor is hormone sensitive).
Perivascular invasionrequires at least two cell types: the endothelial cells that form the vascular tubes and the tumor cells. Perivascular invasion does not
have much significance unless tumor cells are seen inside blood vessels or lymphatic channels, in which case it means there is a greater chance of recurrence ofcancer and a greater likelihood that the cancer might spread to lymph nodes or distant sites.
http://www.breastcancer.org/symptoms/types/dcis/diagnosishttp://www.breastcancer.org/symptoms/types/dcis/diagnosishttp://www.breastcancer.org/symptoms/types/dcis/diagnosis8/11/2019 Ductal Carcinoma Case Study
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JULY 17, 2013
CHEST X-RAY
Both lung fields are clear
Heart, aorta and pulmonary vascular markings are within normal limits
Diaphragm and sinuses are preserved
Intact both thorax
IMPRESSION:
ESSENTIALLY NORMAL CHEST FINDINGS.
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ECG RESULT: NORMAL
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DATE: JULY 17, 2013
TEST VALUE REFERENCE
RANGE
REMARKS
CREATININE 1.63 mg/dl 0.6-1.3 Creatinine increase in certain
kidney disease and infections.
BUN 20.40 mg/dl 7-18 Values increase in response to
increased in dietary protein intake.
GLUCOSE 80.24 mg/dl 70-105 NORMAL
URIC ACID 7.17 mg/dl 2.6-7.2 NORMAL
TRIGLYCERIDES 50.61 mg/dl 0-150 NORMAL
CHOLESTEROL 142.41 mg/dl 0-200 NORMAL
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DATE: July 18, 2013
NAME OF
TESTINDICATION
MICROSCOPIC
EXAMINATIONSRESULTS
REFERENCE
VALUESIGNIFICANCE OF THE RESULT
Urinalysis Urinalysis is a laboratory
diagnostic procedure which
involves testing of urine for
bacteria, protein, or other
molecules that can provide
information about patientshealth.
Color Yellow YELLOW NORMAL
Transparency Slightly
Turbid
CLEAR Indicates high concentration of solutes
Reaction 5.0 4.57.5 NORMAL
Specific Gravity 1.030 1.0151.025 Increased urine specific gravity may be due to:
Dehydration,Diarrhea that causes dehydration,Glucosuria,Heart failure (related to decreased
blood flow to the kidneys), Renal arterial stenosis,
Shock, Syndrome of inappropriate antidiuretic
hormone secretion (SIADH)
CLINICAL TEST
Sugar Negative NEGATIVE NORMAL
Albumin negative NEGATIVE NORMAL
PREGNANCY TEST - - -
URINE BILE - - -
Red Blood Cell 2-3 23HPF NORMAL
Epithelial Cells Few FEW NORMAL
Mucus Threads FEW RARE -
Bacteria MODERATE NEGATIVE -
Crystals - NONE -
Calcium Oxalates - - -
A. Uric Acid - 1.48
4.43mmol/day
-
Fine Granular - NONE -
Course Granular - NONE -
Hyalines - OCCASSIONAL -
Others Yeast cells many
http://www.nlm.nih.gov/medlineplus/ency/article/000982.htmhttp://www.nlm.nih.gov/medlineplus/ency/article/003581.htmhttp://www.nlm.nih.gov/medlineplus/ency/article/000158.htmhttp://www.nlm.nih.gov/medlineplus/ency/article/000394.htmhttp://www.nlm.nih.gov/medlineplus/ency/article/000394.htmhttp://www.nlm.nih.gov/medlineplus/ency/article/000158.htmhttp://www.nlm.nih.gov/medlineplus/ency/article/003581.htmhttp://www.nlm.nih.gov/medlineplus/ency/article/000982.htm8/11/2019 Ductal Carcinoma Case Study
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III. CLINICAL MANIFESTATION
A . ANATOMY AND PHYSIOLOGY
Breast
The breast is the upper ventral region of the torso of a primate, in left and right sides, containing
the mammary gland which in female can secrete milk used to feed infants.
Both men and women develop breasts from the same embryological tissues. However, at
puberty, female sex hormones, mainly estrogen, promote breast development which does not occur
in men due to the higher amount of testosterone. As a result, women's breasts become far more
prominent than those of men.
During pregnancy, the breast is responsive to a complex interplay of hormones that cause tissue
development and enlargement in order to produce milk. Three such hormones are estrogen,
progesterone and prolactin, which cause glandular tissue in the breast and the uterus to change
during the menstrual cycle.
Each breast contains 1520 lobes. The subcutaneous adipose tissue covering the lobes gives the
breast its size and shape. Each lobe is composed of many lobules, at the ends of which are sacs where
milk is produced in response to hormonal signals.
Anatomy
The Breast: cross-section scheme of the mammary gland.
1. Chest wall
2. Pectoralis muscles
3. Lobules
4. Nipple
5. Areola
6. Milk duct
7. Fatty tissue
8. Skin
http://en.wikipedia.org/wiki/File:Breast_anatomy_normal_scheme.pnghttp://en.wikipedia.org/wiki/File:Breast_anatomy_normal_scheme.pnghttp://en.wikipedia.org/wiki/File:Breast_anatomy_normal_scheme.png8/11/2019 Ductal Carcinoma Case Study
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Morphology
The human breast has two aspects: the functional aspect and the anatomic aspect.
The functional breast
The breast is an apocrine gland that produces milk to feed an infant child; for which the nipple ofthe breast is centered in (surrounded by) an areola (nipple-areola complex, NAC), the skin color of
which varies from pink to dark brown, and has many sebaceous glands.
The anatomic breast
In women, the breasts overlay the pectoralis major muscles and usually extend from the level of
the second rib to the level of the sixth rib in the front of the human rib cage; thus, the breasts cover
much of the chest area and the chest walls. At the front of the chest, the breast tissue can extend
from the clavicle (collarbone) to the middle of the sternum (breastbone). At the sides of the chest,
the breast tissue can extend into the axilla (armpit), and can reach as far to the back as the latissimus
dorsi muscle, extending from the lower back to the humerus bone (the longest bone of the upper
arm). As a mammary gland, the breast is an inhomogeneous anatomic structure composed of layers
of different types of tissue, among which predominate two types, adipose tissue and glandular tissue,
which effects the lactation functions of the breasts.
Lymphatic drainage
Approximately 75% of the lymph from the breast travels to the ipsilateral (same-side) axillary
lymph nodes, whilst 25% of the lymph travels to the parasternal nodes (beside the sternum bone), to
the other breast, and to the abdominal lymph nodes. The axillary lymph nodes include the pectoral
(chest), subscapular (under the scapula), and humeral (humerus-bone area) lymph-node groups,
which drain to the central axillary lymph nodes and to the apical axillary lymph nodes. The lymphatic
drainage of the breasts is especially relevant to oncology, because breast cancer is a cancer commonto the mammary gland, and cancer cells can metastasize (break away) from a tumors and be
dispersed to other parts of the woman's body by means of the lymphatic system.
Shape and support
The topography of the breasts indicates the glandular body, the nipple-areola complex (NAC),
and the inframammary fold (IMF).
Size
Breast size varies with race and ethnic origin. A study released in 2013 suggests the existence of a
single genetic mutation responsible for multiple characteristics of East Asians, including thicker hair,more sweat glands and smaller breasts on women.
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Hormonal change
On the skin envelope of the breast, stretch marks may indicate the relative-size increments and
decrements occurred during the life of the woman.
Because the breasts are principally composed of adipose tissue, which surrounds the milk glands,their sizes and volumes fluctuate according to the hormonal changes particular to the larche
(sprouting of breasts), menstruation (egg production), pregnancy (reproduction), lactation (feeding of
offspring), and menopause (end of menstruation). For example, during the menstrual cycle, the
breasts are enlarged by premenstrual water retention; during pregnancy the breasts become
enlarged and denser (firmer) because of the prolactin-caused organ hypertrophy, which begins the
production of breast milk, increases the size of the nipples, and darkens the skin color of the nipple-
areola complex; these changes continue during the lactation and the breastfeeding periods.
Afterwards, the breasts generally revert to their pre-pregnancy size, shape, and volume, yet might
present stretch marks and breast ptosis. At menopause, the breasts can decrease in size when the
levels of circulating estrogen decline, followed by the withering of the adipose tissue and the milk
glands. Additional to such natural biochemical stimuli, the breasts can become enlarged consequentto an adverse side effect of combined oral contraceptive pills; and the size of the breasts can also
increase and decrease in response to the body weight fluctuations of the woman. Moreover, the
physical changes occurred to the breasts often are recorded in the stretch marks of the skin
envelope; they can serve as historical indicators of the increments and the decrements of the size and
the volume of a woman's breasts throughout the course of her life.
REFERENCE: http://en.wikipedia.org/wiki/Breast
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Cellular Aberrations
Ca Cell Proliferation
Disrupt normal cell growth and
interfere with tissue function
Pressure
Obstruction
Pain
Effusion
Ulceration
Vascular Thrombosis, Embolism,
Thrombophlebitis
Malignant cells
produce enzymes,
hormones and other
(Paraneoplastic
Syndrome)
Anemia
Hypercalemia Edema
DIC
Anorexia and
Cachexia Syndrome
Tissue wasting
Severe weight
loss
Severe
debilitation
Reference : Medical Surgical Nursing Concept and Clinical Application 2ndEdition, 2009
Author: Jose, Quiambao, Udab
And
http://www.hopkinsmedicine.org/avon_foundation_breast_center/breast_cancers_other_conditions/invasive_d
uctal_carcinoma.html
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Client Based
Precipitating Factor:
Lifestyle
She like to eat high in salt and fatty foods
Always wearing brassier with wire
Environment
Her breast is often bumped by his son
Predisposing Factor:
Nulliparous or older than 30
years at the birth of a first child
Late menarche
Signs and symptoms:
Lump in the breast
For 5 years
Sore of the breast
Since November 2012 up to august 13
2013
New pain in left side of breast
Cellular Aberrations
Ca Cell Proliferation
Disrupt normal cell growth and
interfere with tissue function
Pressure
Obstruction
Pain
Malignant cells produce
enzymes, hormonesand other
(Paraneoplastic
Syndrome)
Anemia
Ductal Carcinomaoma
Possible complication:
Lymphedema
Bleeding
Hematoma formation
Brachial plexus injuries
http://www.hopkinsmedicine.org/avon_foundation_breast_center/breast_cancers_other_conditions/breast_pain.htmlhttp://www.rightdiagnosis.com/l/lymphedema/intro.htmhttp://www.rightdiagnosis.com/h/hemorrhage/intro.htmhttp://www.rightdiagnosis.com/medical/hematoma_formation.htmhttp://www.rightdiagnosis.com/b/brachial_plexus_injury/intro.htmhttp://www.rightdiagnosis.com/b/brachial_plexus_injury/intro.htmhttp://www.rightdiagnosis.com/medical/hematoma_formation.htmhttp://www.rightdiagnosis.com/h/hemorrhage/intro.htmhttp://www.rightdiagnosis.com/l/lymphedema/intro.htmhttp://www.hopkinsmedicine.org/avon_foundation_breast_center/breast_cancers_other_conditions/breast_pain.html8/11/2019 Ductal Carcinoma Case Study
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Modified Radical Mastectomy
A modified radical mastectomy is a type of mastectomy that combines the removal of all breast tissue
from the affected breast with lymph node removal from the armpit on the affected side of the body.
This surgery typically includes the removal of both the nipple and areola, but the surgery can be
performed using skin and nipple sparing techniques.
Like a simple mastectomy, the procedure is performed using an elliptical incision 6 to 8 inches in length
that begins on the inside of the breast, near the breast bone, and extends upward and outward toward
the armpit. The incision can also be altered to remove scar tissue from previous procedures, which can
improve the cosmetic outcome if reconstruction is desired.
Once the breast tissue is removed, the incision is closed with either absorbable sutures or staples that
are removed during an office visit 10 to 14 days after surgery. There may also be drains in place to
decrease the amount of swelling in the area. These drains are covered with bandages to protect the
incision site and the drain placement. The drains are typically removed after discharge from the hospitalby the surgeon during a routine office visit after surgery.
REFERENCE: http://surgery.about.com/od/proceduresaz/ss/Mastectomy_3.htm
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Name of
Drug
Classification Mechanism of
Action
Indication Contraindication Side Effects Nursing Responsibility
Atracarium
25mg IV
no depolarizing
neuromuscu-lar
blocker
Skeletal Muscle
Relaxant
Prevents
acetylcholine
from binding
to receptors
on muscle end
plate, thus
blocking
depolarization
and resulting
in skeletal
muscle
paralysis.
Adjunct to
general
anesthesia, to
facilitate
endotracheal
intubation and
cause skeletal
muscle
relaxation
during surgery
or mechanical
ventilation
Contraindicated
in patients
hypersensitivity
to drug
Use cautiously
in patients with
CV disease;
severe
electrolyte
disorders,
bronchogeneic
carcinoma;
hepatic, renal,
or pulmonary
impairment;
neuromuscular
diseases; or
myasthenia
gravis; and in
debilitated
patients;
CV
1)Flushing,
2)increased heart
rate,
3)bradycardia
4)hypotension
RESPI
1)Prolonged dose
related apnea,
2)wheezing,
3)increased
bronchial
secretions
SKIN
1)Erythema,
2)pruritus,
3)urticaria
Other
1)anaphylaxis
1. Obtain history of patie
neuromuscular sta
before therapy a
reassess regularly
2. Be alert for adve
reactions and interaction
3. Monitor respiration clos
until patient fully recov
from neuromuscu
blockade, as evidence by
tests of muscle strength
4. Give sedatives or gene
anesthetic befo
neuromuscular blocke
Neuromuscular block
dont decrea
consciousness or alter p
threshold.
5. Dont give by I.M injectio
6. Prior use of succinychol
doesnt prolong duration
action but quickens onand may deep
neuromuscular blockade
7. Give analgesics for pa
Patient may have pain b
unable to express it.
8. Keep airway clear. Ha
emergency equipment a
drugs available.
9. After spontaneous recov
starts, reverse atracariu
induced neuromuscu
blockade with
anticholinesterase (such
neostigmine
endophonium). Thedrugs usually are given w
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Reference: SPRINGHOUSE Nurses Drug Guide 2007 Eight Edition
an anticholnergic (such
atropine)
Name of
Drug
Classification Mechanism of Action Indication Contraindication Side Effects Nursing Responsibilit
Propofol
80mg +
30mg IV
Nonbarbiturate
Anesthetics
(General
Anesthetics)
Exerts its sedative-
hypnotic effects
through a GABAA
receptorinteraction. GABA
is the principal
inhibitory
neurotransmitter in
the CNS.
Indicated for
producing
sedation,
hypnosis,anesthesia,
amnesia,
unconsciousness
to allow
performance of
surgical
procedures.
Status asthmaticus
b/c of the difficulty
in providing
ventilator supportto the patient and
risk of
exacerbation of
the problem with
CNS depression
Absence of suitable
vein for
intravenous
administration
Caution should be
used in cases of
severe
cardiovascular
disease,
hypotension, orshock;
Malignant
hyperthermia
CNS
1)headache
2)prolonged
somnolence3)delirium
CV
1)hypotension
2)shock
3)decreased
cardiac output
4)arrhythmias
RESPI
1)respiratory
depression
2)laryngospasm
3)bronchospasm
4)hiccups
5)coughing
GI1)nausea
2)vomiting
1. Assess for any kno
allergy to gene
anesthetics; impai
liver or kidnfunction; myasthe
gravis; history
malignant
hyperthermia;
cardiac or respirat
disease
2. Include screening
baseline sta
before beginn
therapy and for a
potential adve
effects.
3. The drug must
administered
trained personnel4. Have equipment
standby to maint
airway and prov
mechanical
ventilation
5. Monitor temperat
for prompt detect
and treatment
malignant
hyperthermia
6. Monitor pu
respiration, blo
pressure and card
output dur
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Reference: SPRINGHOUSE Nurses Drug Guide 2007 Eight Edition
administration
(dosage adjustm
may be needed
alleviate poten
problems a
maximize ove
benefit with the le
toxicity
7. Monitor the pati
until recovery pha
is complete and t
patient is conscio
able to move a
communicate
ensure patient safe
8. Provide comf
measures to h
patient tolerate dru
9. Provide pain relief
appropriate, skin c
and turning
prevent s
breakdown,
supportive care
conditions such
hypotension a
bronchospasm10.Offer support a
encouragement
help the patient co
with procedure a
the drugs being use
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Name of
Drug
Classification Mechanism of Action Indication Contraindicatio
n
Side effects Nursing Responsibility
Butorphanol
1mg IV
Opioid agonist-
antagonist
Analgesic, adjunct to
anesthesia
Binds with opiate
receptors in CNS,
altering both
perception of and
emotional response
to pain through
unknown mechanism
Moderate to
severe pain
Preoperative
anesthesia or
preanesthesia
Adjunct to
balance
anesthesia
Contraindicat
ed in patients
with opioid
addiction;
may
precipitate
withdrawal
syndrome.
Patients with
hypersensitivi
ty to drug or
preservative
(benzethoniu
m chloride)
Use
cautiously in
patients with
head injury,
increase
intracranial
pressure,
acute MI,
ventricular
dysfunction,
coronary
insufficiency,
respiratory
disease or
renal and
hepatic
dysfunction.
CNS
1) sedation
2) headache
3) vertigo
4) floating sensation
5) lethargy
6) confusion
7) nervousness
8) unusual dreams
9) agitation
10) euphoria
11) hallucinations
12)
flushing
CV
1) palpitations
2) fluctuation in
blood pressure
EENT
1) diplopia
2) blurred vision
3) nasal congestion
(with nasal spray)
GI
1) Nausea
2) vomiting
3) constipation
4) dry mouth
RESPI
1) Respiratory
depression
SKIN
1) Rash
2) Urticaria
3) Clamminess
4) Excessive sweating
1. Obtain history of patients p
before therapy, and reas
during therapy
2. Be alert for adverse reaction
drug interactions
3. Periodically monitor p
operative vital signs and blad
function. Drug decreases b
rate and depth respirations
monitoring arterial oxy
saturation may aid in asses
respiratory depression.
4.
Caution ambulatory patient
get out of bed slowly and w
carefully until CNS effects
known.
5. Warn outpatient to refrain f
driving and performing ot
activities that require me
alertness until drugs CNS eff
are known
6. Warn patient that drug
cause physical and psycholog
dependence. Tell him to
drug only as directed and t
abrupt withdrawal a
prolonged use produces inte
withdrawal symptoms.
Reference: SPRINGHOUSE Nurses Drug Guide 2007 Eight Edition
Name of Drug Classification Mechanism of
Action
Indication Contraindication Side effects Nursing Responsibilit
Neostigmine 5mg
+ Atropine Sulfate
1 mg
Cholinesterase
Inhibitor
Muscle
stimulant
Inhibits
destruction of
acetylcholine
released from
parasympatheti
Myasthenia
gravis
To diagnose
myasthenia
gravis
Contraindicated
in patient
hypersensitive
to cholinergics
or bromide and
CNS
1) dizziness
2) Headache
3) Mental Confusion
CV
1) Bradycardia
1. Assess patie
condition befo
starting therapy
2. Monitor patien
response after ea
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c and somatic
efferent
nerves.
Acetylcholine
accumulates,
increasing
stimulation of
receptor.
Postoperative
abdominal
distention and
bladder atony
Antidote for
nondepolarizing
neuromuscular
blockers
Supraventicular
tachycardia
from tricyclic
antidepressant
overdose
Decrease small
bowel transit
during
radiography
in those with
peritonitis or
mechanical
obstruction
Use cautiously
in patient with
renal
impairment,
neuromuscular
disorders or
ulcerative bowel
lesions
2) Hypotension
3) Cardiac arrest
EENT
1) Blurred vision
2) Lacrimation
3) miosis
GI
1) Nausea
2) Vomiting
3) Diarrhea
4) Abdominal cramps
5) Excessive
salivation
GU1) Urinary frequency
MUSCULOSKELETAL
1) Muscle cramps
2) Muscle weakness
3) Muscle
fasciculation
RESPI
1) Depressed
respiratory drive
2) Bronchospasm
3) Bronchoconstricti
ons
4) Respiratory arrest
SKIN
1) Rash (with
bromide)
2) diaphoresis
Other1) Hypersensitivity
reaction
2) Anaphylaxis
dose. Watch clos
for improvement
strength, vision, a
pstosis 45 to
minutes after ea
dose. Show pati
how to reco
variations in mus
strength.
3. Monitor V
frequently
4. Although drug is
commonly used
reverse effects
nondepolarizing
neuromuscular
blockers in pati
who ha
undergone surge
it may wors
blockade produc
by succinylcholine
5. Patient may deve
resistance to drug
6. Give oral drug w
food or milk
reduce GI distress
Anticholinergic,
belladonna
alkaloid
Antiarrythmic,
vagolytic
Inihibits
acetylcholine
at
parasympatheti
c neuroeffector
junction,
blocking vagal
effects on SA
node. This
enhances
Anticholinestera
e insecticide
poisoning
Preoperatively
for decreasing
secretions and
blocking cardiac
vagal reflexes
Contraindicated
in patients
hypersensitive
to drug and
those with
acute angle-
closure
glaucoma,
obstructive
uropathy,
CNS
1) Headache
2) Restlessness
3) Ataxia
4) Disorientation
5) Hallucinations
6) Delirium
7) Coma
8) Insomnia
9) Dizziness
10) Excitement
11) Agitation
12) confusion
1. Obtain history
patients underly
condition a
reassess regularly
2. Be alert for adve
reaction and d
interaction
3. Monitor patie
especially tho
receiving doses
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through AV
node and
speeds heart
rate.
obstructive
disease of GI
tract, paralytic
ileus,toxic
megacolon,
intestinal atony,
unstable CV
status in acute
hemorrhage,
asthma, or
myasthenia
gravis
Use cautiously
in patient with
Down syndrome
CV
1) Tachycardia
2) Palpitations
3) Angina
4) Arrhythmias
5) flushing
EENT
1) Photophobia
2) Blurred vision
3) Mydriasis
GI
1) Dry mouth
2) Thirst
3) Constipation
4)
Nausea5) vomiting
GU
1) Urine retention
Hematologic
1) leukocytosis
Other
1) anaphylaxis
0.4 to 0.6 mg ,
paradoxical ini
bradycardia, wh
is caused by a d
effect in CNS a
usually disappe
within 2 minutes
4. Watch
tachycardia
cardiac patie
because it m
cause ventricu
fibrillation
5. Give with or witho
food
6. If ECG disturban
occur, withh
drug, obtain
rhythm strip, a
notify prescri
immediately
7. Have emerge
equipment a
drugs on hand
treat n
arrhythmias. Ot
anticholinergics mincrease va
blockage
8. Use physostigm
salicylate
antidote
atropine overdose
9. Teach patient h
to handle distress
anticholinergic
effect.
Reference: SPRINGHOUSE Nurses Drug Guide 2007 Eight Edition
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early Lyme
disease
Reference: Nursing Pharmacology 4th Edition-Amy Karch
Name of Drug Classification Mechanisms of
Action
Indication Contraindication Side effects Nursing
Responsibilities
Keterolac Nonsteroidal
anti-
inflammatory
agents
nonopioid
analagesics
Inhibits
prostaglandin
synthesis,
producing
peripherally
mediated
analgesia
Also has
antipyretic and
anti-
inflammatory
properties.
Therapeutic
effect:Decreased
pain
Short
term manage
ment of pain
Hypersensitivity
Cross-sensitivity
with other NSAIDs
may existPre- or
perioperative use
Known alcohol
intoleranceUse
cautiously in:
1) History of GI
bleeding
2) Renal impair-
ment (dosage
reduction may be
required)
3) Cardiovascular
disease
CNS
1)drowsiness
2)abnormal
thinking
3)dizziness
4)euphoria
5)headache-
RESP
1)asthma
2)dyspnea
CV
1) edema
2) pallor
3) vasodilation
GI
1) GI Bleeding
2) abnormal
taste
3) diarrhea
4) dry mouth
5) dyspepsia6) GI pain
7) nausea
GU
1) oliguria
2) renal toxicity
3) urinary
frequency
DERM
1) pruritis
2) purpura
3) sweating
4) urticaria
HEMAT
Patients who ha
asthma, aspi
induced aller
and nasal poly
are at increas
risk
developing
hypersensitivity
reactions. Ass
for rhini
asthma, a
urticaria.
Assess pain (n
type, locati
and intens
prior to and 1-2
following
administration.
Ketorolac thera
should always
given initially the IM or
route. O
therapy should
used only as
continuation
parenteral
therapy.
Caution patient
avoid concurr
use of alcoh
aspirin, NSAI
acetaminophen
or other O
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1) prolonged
bleeding time
LOCAL
1) injection site
pain
NEURO
1) paresthesia
- MISC:
1) allergic
reaction,
anaphylaxis
medications
without
consulting hea
care profession
Advise patient
consult if ra
itching, vis
disturbances,
tinnitus, wei
gain, edem
black sto
persistent
headche,
influenza-like
syndromes
(chills,fever,mu
es aches, pa
occur.
Effectiveness
therapy can
demonstrated
decrease
severity of pa
Patients who
not respond
one NSAIDs m
respond another.
Name of Drug Classification Mechanisms of
Action
Indication Cotraindication Side effects Nursing Responsibilitie
Tramadol Analgesics Binds to mu-
opioid receptors
and inhibits the
reuptake
ofnorepinephrine
and serotonin;
causes many
effects similar to
Relief of
moderate to
moderately
severe pain
Contraindicated
with pregnancy;
allergy
to tramadol;
acute intoxication
with
alcohol, opioids,
psychotropic
1. Sedation,
2. dizziness/vertigo
3. headache
4. confusion
5. Dreaming
6. Sweating
7. Anxiety
8. Seizures
1. Assess for level of p
relief and adminis
prn dose as need
but not to exceed
recommended to
daily dose.
2. Monitor vital signs a
assess for orthosta
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theopioids--
dizziness,
somnolence,
nausea,
constipation--but
does not have
the respiratory
depressant
effects.
drugs or other
centrally acting
analgesics;
lactation.
Use cautiously with
seizures,
concomitant use
of CNS
depressants
or MAOIs, renal
or hepatic
impairment
9. Hypotension
10.Tachycardia
11.Bradycardia
12. Sweating
13. Pruritus
14. Rash
15.pallor,
16. urticaria
17. Nausea and
vomiting,
18. dry mouth
19.constipation
20.flatulence
hypotension or signs
CNS depression.
3. Discontinue drug a
notify physician if S
of hypersensitiv
occur.
4. Assess bowel a
bladder functi
report urin
frequency
retention.
5. Use seiz
precautions
patients who have
history of seizures
who are concurren
using drugs that low
the seizure threshold
6. Monitor ambulat
and take appropri
safety precautions.
REFERENCE:http://www.nursing-nurse.com/drug-study-tramadol-178/
Name of Drug Classification Mechanism of Action Indication Contraindication Side Effects Nursing Responsibilit
Paracetamol
300mg IV q4
Non-
narcoticanalgesic
Antipyretic
Decreases fever
by a hypothalamiceffect leading to
sweating and