case study on fcbd

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I. INTRODUCTION

It is common for women to develop breast lumps. During menstruation and menopausal

our hormones change, levels of progesterone, estrogen, prolactins becomes variant. These

change in hormone levels initiate the production of lumps in which most women are so

worried about. Most of the women see their doctors to be diagnosed and treated, some

doesn’t care and leave the lump as it is until it gets worst. One common diagnosis of

breast lumps is Fibrocystic Breast Disease. Fibrocystic Breast Disease is a condition

of breast tissue affecting an estimated 30-60% of women. Fibrocystic breast disease is

usually a benign (non-cancerous) condition which includes symptoms of swollen, tender

breasts, and/or one or more lumps. Frequently, symptoms worsen just before a woman's

menstrual cycle and lessen near the end.

This case was chosen to increase the awareness of the women about their health and how

lifestyle and diet affects them. Some argue that fibrocystic breast disease is

not a disease, but a common and harmless condition experienced by

women as they encounter hormonal changes during their menstrual

cycles. Others argue that fibrocystic breast changes are a precursor for

future breast cancer. Cancerous or benign it may be, women must

know how to deal with lumps. This study should make women realize

that breast self exam and doctor’s check up is important. As well as

changing unhealthy lifestyle and diet so that abnormalities can be

prevented. This study about Fibrocystic Breast Disease aims to correct

any misconceptions about breast lumps.

http://womenshealth.about.com/cs/cancer/index.htm

http://womenshealth.about.com/cs/menstruation/index.htm

http://womenshealth.about.com/cs/menstruation/index.htm

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II. GENERAL DATA

HOSPITAL : PATIENTS NAME : ADDRESS :

AGE : SEX :

OCCUPATION :

CIVIL STATUS :

RELIGION :

CITIZENSHIP :

BIRTHDATE : MENARCHE :

OB SCORE :

CHIEF COMPLAINTS:

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III. HEALTH ASSESSMENT

A. HEALTH HISTORY

A.1 Biological dataOne year prior to admission patient noted right breast mass but did not sought consult so no interventions were given. 3 days prior to admission patient noted swelling of the breast with associated pain thus prompted consult.A.2 Reason for seeking consultRight breast lump with associated pain.A.3 Current Health StatusPatient was received lying on bed, conscious, responsive, coherent, time place and person oriented with ease in respiration. She is having an ice pack on her incision site and is experiencing mild pain on the incision site. A.4 History of Present IllnessOne year PTA, patient noted right breast mass. She did not consult a physician that time so no medical interventions were given.A.5 Past Health HistoryPatient was hospitalized due to C-section on her first baby. Patient had no significant childhood illnesses. She had her 3rd dose on Hepatitis B last March 2009. She has no known allergies. She sleeps 10pm and wakes up 5am.A.6 Review of Systems

GORDONS HEALTH PATTERN•HEALTH MAINAINANCE – PERCEPTION PATTERNPatient was relieved when the cancer impression was ruled out and so she describes her health as good. She doesn’t have any maintenance medications and is taking vitamins to stay healthy. She further said that doesn’t want to be psychomatic because of stress so se balances her time with her family and work. She is stated that she is taking good care of her child that she thinks she is being a good mother and wife.•NUTRITIONAL- METABOLIC PATTERNPatient eats 3 times a day. She eats vegetables, meat, and fish. Her favorite food is adobo. She drinks 2-3 L of water a day. She stated that her appetite is good and she doesn’t have any problems in eating.•ELIMINATION PATTERNPatient verbalized that she had difficulty in defecating before because she had hemorrhoids but she managed through it and is now emptying her bowel once a day usually in the morning. She also urinates frequently and does not feel pain during urination. •ACTIVITY AND EXCERSICE PATTERNPatient actively involves herself in exercise by walking around their house and watering her plants during days of no work. She can walk freely

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without feeling pain and auxiliary equipments to use. Sometimes she experience fatigue because of her work.•SLEEP-REST PATTERNPatient sleeps less than 8 hours a day. She goes to bed around 10pm and wakes up around 5am. Patient doesn’t have any difficulty in sleeping. She doesn't use sleeping pills.•COGNITIVE-PERCETUAL PATTERNPatient doesn’t use any eyeglasses, contact lens, and prosthesis. She can see clearly without abnormalities. She can read and write with an educational attainment of college degree.•SELF-PERCEPTION PATTERNShe consults her physician when it comes to the health of her family. She and her husband make the decision in their family. Her present health goal is to be a health oriented person and avoid practices that would danger her family’s health and hers too.•ROLE-RELATIONSHIP PATTERNPatient is can to speak English, bisaya, tagalog. She speaks clearly and coherently. She lives with her husband and child. When it comes to problems, she seeks help to her husband and especially to God. •SEXUALITY-REPRODUCTIVE PATTERNPatient has one child. She gave birth to her child when she was 28 years old. They use natural family planning method. She had her menarche when she was 12 years old.•COPING-STRESS MANAGEMENT PATTERNPatient decides with the help of his husband. There were no changes or loss in the past years. Whenever she experience stress, she watches TV, have a rest and sleeps early. •VALUE-BELIEF PATTERNPatient is a roman catholic. She actively participates mass every Sunday together with her family. Her source of strength is her family and God.

A.7 Psychosocial Profile•PERSONAL AND SOCIAL HISTORYThe patient is a certified public accountant. She sometimes do her paper works during night time but still finds time for her child. She wakes up early, and goes to work 8:30 in the morning. She eats a light breakfast with her family. Patient has a good relationship with her neighbors, she has no known rivals or enemies.•ENVIRONMENTAL HISTORYPatient lives in a less polluted area. It is located slightly away from the streets. Free from noise pollution, subdivision-type environment. There is adequate space for the family and they use electricity as source of energy. They properly dispose their waste, waste are collected by the garbage truck. Water source is from MCWD.

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•HEREDO-FAMILIAL HISTORY

B. PHYSICAL ASSESMENT

Received client lying in bed, awake, responsive, coherent,afebrile with an ongoing IVF #2 D5LR 1L regulated at 120cc/hr, infusing well at the left arm. With the ff. vital signs:

Temperature: 36.2cPulse Rate: 76 bpmRespiratory Rate: 17 cpmBlood Pressure: 110/70 mmHg

•NEUROSENSORY/COGNITIVE/PERCEPTUAL

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Client is alert, responsive and coherent. She is time place and person oriented. She has adequate hearing and adequate visions. She speaks normally and can speak English, Bisaya and Tagalog. •RESPIRATORYHer chest is symmetrical, normal in breathing pattern. She can inhale and exhale without feeling pain and doesn’t use accessory muscles in breathing. Respiratory expansion is equal. During auscultation no crackles or abnormal sounds were heard. •CARDIOVASCULARNo cyanosis or edema was noted. Extremities are well perfused. Patient’s heart rhythm is regular. Radial pulse was felt. •GASTROINTESTINAL METABOLLIC PATTERNShe is on a full diet without fluid and water restrictions. There were no complaints of difficulty in swallowing and difficulty in defecating. Patient defecates regularly every morning.•MUSCOSKELETAL SYSTEMShe is not experiencing any fatigue or muscle pains. Client has good posture. Patient can perform ROM without feeling pain. No masses or tenderness were noted at the extremities.•GENITO-URINARY SYSTEMClient had her menarche when she was 13 years old. She is not experiencing menstrual problems. Patient does not feel any pain during urinating. Urine is light yellow in color.

IV. ANATOMY AND PHYSIOLOGY OF THE SYSTEM INVOLVED

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The breasts are composed of fatty tissue that contains the glands responsible for milk production in late pregnancy and after childbirth. Within each breast, there are about 15 to 25 lobes formed by groups of lobules, the milk glands. Each lobule is composed of grape-like clusters of acini (also called alveoli), the hollow sacs that make and hold breast milk. The lobules are arranged around ducts that funnel milk to the nipples. About 15 to 20 ducts come together near the areola (dark, circular area around the nipple) to form ampullae - cavities that store the milk before it reaches the nipple surface. Montgomery's glands are small oil glands that are located around each areola. They release a lubricant that protects the nipples during nursing.Breast Size And ShapeThe breasts are not always exactly the same size or shape. They are incompletely developed at birth and - in men - remain small and undeveloped unless subjected to abnormal hormonal stimulation. In general, breast formation is complete within a year or two after the start of menstruation; however, the acini keep growing, and fibrous and fatty tissues are continually added during adolescence. Pregnancy and nursing cause further increases in breast size. As a woman ages, the fatty tissue of the breasts may become more prominent than the glandular tissue, and the breasts may feel softer. The breasts gradually atrophy (shrink) after menopause (the end of menstruation).Breast Position

The breasts cover a large part of the chest wall. In front, the breast tissue may extend from the clavicle (collarbone) to the middle of the sternum (breastbone). On the side, breast tissue may continue into the axilla (armpit) and reach as far as the latissimus dorsi (muscle extending from the lower back to the humerus bone of the upper arm). In fact, the anatomic relationship between the breasts and the underlying muscle is a very impor-tant consideration in surgical therapy. The breasts overlay vital chest wall muscles such as the pectoralis major (the 'pecs'), the pectoralis minor (thin, triangular muscle beneath the pecs), and the intercostals (muscles between the ribs). The breasts also may cover some of the serratus magnus (also called the serratus anterior; a slender muscle that is at-tached to the ribs/ rib muscles and connects with the shoulder blade) and the rectus abdo-minis (long, flat muscle that stretches up the torso from the pubic bone to the ribs).

Lymphatic System

Lymph is a clear, tan fluid that contains lymphocytes (white blood cells that fight dis-ease). Lymph is drained from the breast tissues by a rich supply of vessels. Such lym-phatic vessels connect with a network of lymph nodes that are located around the breasts' edges or in nearby tissues of the armpits and collarbone. The breasts' lymph nodes are not linked in a straight line. Instead, they are staggered and fixed within fat pads - an arrange-ment that complicates lymph node removal during breast cancer surgery.

Lymph nodes play a central role in the spread of breast cancer. The axillary (underarm) lymph nodes are particularly important, as they are among the first places that cancer is likely to be found if it metastasizes (spreads) from the breast. This lymph node cluster is

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often referred to as the 'tail,' or level I nodes. Level II nodes are located underneath the pectoralis minor muscle, and level III nodes are found near the center of the collarbone.

V. CONCEPTUAL FRAMEWORK OF THE DISEASE CONDITION

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VI. THEORETICAL FRAMEWORK OF THE PATHOPHYSIOLOGY OF THE DISEASE CONDITION

Fibrocystic breast condition involves the glandular breast tissue. The sole known biologic function of these glands is the production, or secretion, of milk. Occupying a major portion of the breast, the glandular tissue is surrounded by fatty tissue and support elements. The glandular tissue is composed of different types of cells: (1) clusters of secretory cells (cells that produce milk) that are connected to the milk ducts (tiny tubes); and (2) the cells that line the surfaces of the secretory cells, called the epithelial cells.The most significant contributing factor to fibrocystic breast condition is a woman's normal hormonal variation during her monthly cycle. Many hormonal changes occur as a woman's body prepares each month for a possible pregnancy. The most important of these hormones are estrogen and progesterone. These two hormones directly affect the breast tissues by causing cells to grow and multiply.Many hormones aside from estrogen and progesterone also play an important role in causing fibrocystic breasts. Prolactin, growth factor, insulin, and thyroid hormone are some of the other major hormones that are produced outside of the breast tissue, yet act in important ways on the breast. In addition, the breast itself produces hormonal products from its glandular and fat cells. Signals that are released from these hormonal products are sent to neighboring breast cells. The signals from these hormone-like factors may, in fact, be the key contributors to the symptoms of fibrocystic breast condition. These substances may also enhance the effects of estrogen and progesterone and vice versa.The same cyclical hormones that prepare the glandular tissue in the breast for the possibility of milk production (lactation) are also responsible for a woman's menstrual period. However, there is a major difference between what happens in the breast and uterus.In the uterus (the womb), these hormones promote the growth and multiplication of the cells lining the uterus. If pregnancy does not occur, this uterine lining is sloughed off and discharged from a woman's body during menstruation.In the breast, these same hormones stimulate the growth of breast glandular tissue and increase the activity of blood vessels, cell metabolism, and supporting tissue. All this activity may contribute to the feeling of breast fullness and fluid retention that women commonly experience before their menstrual period.When the monthly cycle is over, however, these stimulated breast cells cannot simply slough away and pass out of the body like the lining of the uterus. Instead, many of these breast cells undergo a process of programmed cell death, called apoptosis. During apoptosis, enzymes are activated that start digesting cells from within. These cells break down and the resulting cellular fragments are then further broken down by scavenger cells (inflammatory cells) and nearby glandular cells.During this process, the fragments of broken cells and the inflammation may lead to scarring (fibrosis) that damages the ducts and the clusters (lobules) of glandular tissue within the breast. The inflammatory cells and some of the breakdown fragments may release hormone-like substances that in turn act on the nearby glandular, ductal, and structural support cells.

VII. CLINICAL MANAGEMENT

A. MEDICAL MANAGEMENT

http://www.medicinenet.com/script/main/art.asp?articlekey=42809

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A.1 LABORATORY AND DIAGNOSTIC EXAMINATIONS

FROZEN SECTION REPORT (7-22-10)

ULTRASOUND (7-21-10)

CLINICAL CEMISTRY REPORT (7-21-10, AT 1:28PM)

HEMATOLOGY REPORT (7-21-10 AT 9:31PM)

HEMATOLGY REPORT (7-21-10 AT 9:20 PM)

Examination: Frozen Section with BiopsySpecimen: Right breast massResult: Fibrocystic change with Chronic Mastitis

Examination: LiverReport: Liver span of 13.7. The liver is within normal limits in size and erogeneity. Configuration and lobar proportions are physiologic. Parenchyma is fairly homogenous, no definite abnormal solid masses or focal cystic lesions are seenImpression: Structurally normal and intact liver

TEST RESULT REFERENCECreatinine 0.8 0.6-1.5Alkaline phosphatase 40 45.5-125.0

Result Reference UnitBleeding Time4.23 mins 2.3-9.5 Minutes

COMPLETE BLOOD COUNTRESULT REFERENCE

•WBC 6.10 4.8-10.8•RBC 4.76 4.2-5.4•HEMOGLOBIN 11.8 12.0-16.0•HEMATOCRIT 36.2 37.0-47.0•PLATELET 219 130-400BLOOD INDICES•MCV 76.0 81-99•MCH 24.9 27.0-31.0•MCHC 32.7 33.0-37.0•RDW 12.1 11-16•PDW 13.8 9.0-14.0•MPV 9.1 7.2-8.11ABSOLUTE DIFFERENTIAL COUNT•NEUTROPHIL 3.59 1.9-8.0•LYMPHOCYTE 2.27 0.9-5.2•MONOCYTE 0.13 0.16-1.00•EOSINOPHILS 0.11 0.0-0.8•BASOPHILS 0.01 0.0-2

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CHEST X-RAY (7-21-10)

A.2 DIET

Patient is having a full diet now. She eats meat and rice during meals and 2-3L of water

everyday.

A.3 MEDICATIONS

• Omeprazole (Omepron) 40 mg IVTT

Examination: Chest X-RAYReport: Lungs are clear, Heart is not enlarged, the tracheal air column is at the midline. Both hemidiaphragms and costophrenic sulci are intact.

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• Alprazolam (xanax) 0.5mg/tab

• Parecoxib (dynastat) 40 mg IVTT

• Nalbuphine (Nubain) 5mg slow IV push

• Etoricoxib (Arcoxia) 120mg/tablet

A.4 DOCTOR’S ORDERS

7-21-20105PM

-request for serum creatinine,ALP,CBC, Ultrasound of the liver, prothrombin time, chest x-ray ,ECG 12 Leads-schedule for excision of Right breast mass•DR. Crisostomo Dy

RATIONALE: to check for renal dysfunction,damage or obstruction, for determining the clotting time or check for any bleeding problems, to detect the presence of cysts or infections in the liver.

7-21-108pm

-Problems: 1. Right Breast Mass 2. Fear-I&O q shift, BP & TPR every 4 hours•Dr. Rowena Maguad

RATIONALE: to monitor abnormalities of the patient’s vital signs, and observe for dysfunction of the renal and GI system.

7-21-108:15pm

-please get 2 hours post-supper hct•Dr. Carolyn Fermin

RATIONALE: to evaluate anemia, polycythemia, response to treatment of anemia or polycythemias, dehydration.

7-21-109pm

-start venolysis D5LR @120cc per hour at left arm at 8am-Omepron 40 mg IVTT 1 dose at 6am-Alprazolam .5mg/tab 1 dose at 9 pm•Dr. Doveeral

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RATIONALE: to suppress gastric secretion before surgery, to treat patient’s anxiety, and provide extra calories for the patient

7-21-101:35am

-patient has no absolute contraindications to contemplated procedure-may go with surgery•DR. Carolyn Fermin

RATIONALE: to inform the surgeon to go on with the procedure

7-22-1012:30pm

-Post operative anesthesia orders: ○Monitor v/s every 5 min for 15 min, every 15 min for 5 hour- regulate IVF at 120cc/hr-IV to follow D5LR at 120 cc/hrMeds:○ Give parecoxib (dynastat) 40 mg IVTT A@ 9pm tonight Close mainline and flush 5cc NSS before and after administration○ Give Nalbuphine(Nubain) 5mg slow IV push every 8 hours8am, 4pm, 12 midnight for pain scale of greater than or equal to 4/10○ Give Etoricoxib(Arcoxia) 120mg/tablet orally once a day for 3 days-refer for nausea, vomiting, dizziness, hypotension, BP<90/60, priritus•DR. Clive Roland Fermin

RATIONALE: to provide extra calories for the patient, to relieve post-operative pain, for preoperative and postoperative analgesia.

7-22-1012:30pm

-specimen at the right breast for histopathology-apply cold compress over post op site•DR. Joevin Yu

RATIONALE: to check for any malignancy of the breast, to promote faster healing of the wound

http://www.rxlist.com/script/main/art.asp?articlekey=2234



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7-23-1012:40pm

-May go home-take home meds: Etoricoxib(Arcoxia) 120mg/tablet OD P.O.•DR. Dy

RATIONALE: to relieve post-operative pain

7-23-102pm

-Okay for dischargeDr. Neil Wayne Salces

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IVF STUDY

TYPE OF SOLUTION

CLASSIFICATION

CONTENT MECHANISM OF ACTION

INDICATIONS CONTRA-INDICATIONS

HOWSUPPLIED

DOSE

NURSINGRESPONSIBILITY

Lactated Ringer’s Solution with 5% Dextrose(D5LR)

Hypertonic Sodium: 130mmol;Potassium: 4mmol;Calcium: 1.4mmol;Chloride: 109 mmol;Lactate: 28mmol

This pulls the fluid into the vascular by osmosis, resulting in an increase in an increase vascular volume. It raises intravascular osmotic pressure and provides fluid, electrolytes, and calories for energy.

Treatment for persons needing extra calories who cannot tolerate fluid overload.Treatment for shock.

Hypersensitivity to any components.

1000ml baxster

1L @120cc/hr

*check doctor’s order*do not administer unless solution is clear, and container is undamaged.*Sol’n with dextrose should be used with caution in pt. with known DM.*discard unused portion*document time and date of administration.

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GENERIC & BRAND NAME

ORDER, DOSAGE AND STRENGTH

INDICATION/MECHANISM OF ACTION

ADVERSE EFFECTS/ DRUG INTERACTIONS

NURSING ACTIONS

RATIONALE CLIENT TEACHING

Generic Name : Omeprazole

Brand Name:

Omepron

Classification :

proton pump inhibitors

Ordered:Give Omepron 40 mg IVTT 1dose at 6am

Timing:6am

Duration:30min-2hr

Other Forms:

20 mg capsules40mg vial

Indications: Barrett's Esophagus,Duodenal Ulcer,Erosive Esophagitis, GERD,Helicobacter,Pylori Infection,Indigestion, Stomach Ulcer, Systemic Mastocytosis,Zollinger-EllisonSyndromeMechanism of Action:Suppresses gastric secretion by inhibiting hydrogen/potassium ATPaseenzyme system in the gastric parietal cell: characterize as a gastric acidpump inhibitor, since it block the final step of acid production

Adverse effects:Headache, dizziness, insomia, apathy, anxiety, rashes, pruritus, nausea, vomiting, abdominal pain, cough

Interactions:

Drug-drug:Ampicillin esters, iron derivatives,Ketononazole – decrease

-assess for hypersensitivity to the drug-Assess G.I. system for pain. loss of appetite, swelling-Assess vital signs every 4 hours- Monitor therapeuticeffectiveness andadverse reaction at the beginning Of therapy andperiodicallythroughout thetherapy-administer capsules before meals

-to prevent complications

-may indicate adverse reactions

-to monitor any abnormalities -to check the progress of the condition

-for increased absorbption

-teach patient for the side effects, actions, interactions of the drug-instruct patient not to drive-instruct patient to have a proper and healthy diet -instruct patient not to self medicate when having coughs

http://www.drugs.com/condition/systemic-mastocytosis.html

http://www.drugs.com/condition/systemic-mastocytosis.html

http://www.drugs.com/condition/gastric-ulcer.html

http://www.drugs.com/condition/dyspepsia.html

http://www.drugs.com/condition/helicobacter-pylori-infection.html

http://www.drugs.com/condition/helicobacter-pylori-infection.html

http://www.drugs.com/condition/gastroesophageal-reflux-disease.html

http://www.drugs.com/condition/erosive-esophagitis.html

http://www.drugs.com/condition/erosive-esophagitis.html

http://www.drugs.com/condition/duodenal-ulcer.html

http://www.drugs.com/drug-class/proton-pump-inhibitors.html

http://www.drugs.com/drug-class/proton-pump-inhibitors.html

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NURSING ACTIONS


Generic Name :

alprazolam

Brand Name:

Xanax

Classification :

Anxiolytic

Ordered:

Give alprazolam (xanax) 0.5mg/tab one dose at 9pm

Timing:9pmDuration:1-2hr

Other Forms:Tablets—0.25, 0.5, 1, 2 mg; XR tablets—0.5, 1, 2, 3 mg; intensol solution—1 mg/mL

Indications: Management of anxiety disorders, short-term relief of symptoms of anxiety; anxiety associated with depression,Treatment of panic attacks with or without agoraphobia, Mechanism of Action:main sites of action may be the limbic system and reticular formation; increases the effects of gamma-aminobutyrate, an inhibitory neurotransmitter; anxiety blocking effects occur at doses well below those necessary to cause sedation, ataxia.

Adverse effects:Confusion, agitation, anxiety,Depression, dizziness, fatigue, headache, constipation, diarrhea, dry mouth,Interactions:

Drug-drug:Barbiturates, opoiods,Benzodiazepines-May increase CNS deppresant effects

Drug-fruit:Grapefruit- may increase d rug level

-assess patient’s anxiety before and often after drug therapy-Monitor liver, renal, hematopoetic laboratory results

-be alert for adverse reactions-Make sure that the drug are swallowed by the patient-be alert for seizures

-assess v/s every 4 hours

-to monitor drug effectiveness

-for patients undergoing drug regimen for 4 months, drug may cause liver and renal disorders-to prevent complications-to ensure proper administration of the drug-may indicate withdrawal symptoms-to monitor V/S

-warn patient to avoid hazardous activites that require alertness (e.g. driving)-advice patient to avoid alcohol and smoking-teach for drug actions, indications and adverse effects-teach pt. to adhere to doctor’s orders

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NURSING ACTIONS


Generic Name : Paracetamol

Brand Name:Tylenol

Classification : Antipyretic, analgesic

Ordered:May give paracetamol forhigh fever every 4 hoursTiming:

8am,12noon,4pm,8pm

Duration:10-60min

Other Forms:Caplets: 165,500650mgCapsules:500mgElixir: 80mg/2.5mL,80mg/5ml,120mg/5mLGeltab: 500mgTablets: 160 mg, 325 mg, 500mg

Indications: Mild pain or fever

Mechanism of Action:Its mechanism of action is not clearly established. It appears that paracetamol inhibits prostaglandin biosynthesis in the central nervous system but not (or hardly) in the peripheral tissues. In any case, paracetamol only has minimal anti-inflammatory action compared to non-steroidal anti-inflammatory agents

Adverse effects:Leucopenia, thrombocytopenia,Neutropenia, hypoglycemia

Interactions:Drug-Drug:Isoniazid,Rifampin-May reduce therapeutic effects and enhance hepatotoxicity

-observe proper administ ration of the drug-Assess V/S

-be alert for drug interactions and adverse reactions

-Assess patients knowledge about the therapy

-Encouraged increase intake of foods especially carbohydrates


-to monitor patients vital signs-to give immediate intervention

-to provide information betweenknowledge gaps-to reduce risk of hypoglycemia

-advice patient to take drug during the day to avoid sleep interruption cause by nocturnia-Teach pt. to monitor fluid volume by measuring weight, intake and input daily-encourage pt. to avoid high sodium foods-teach pt. for electrolyte imbalance

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NURSING ACTIONS


Generic Name : Parecoxib

Brand Name: Dynastat

Classification : COX2 selective inhibitor

Ordered:Give parecoxib (dynastat) 40 mg IVTT A@ 9pm tonight

Timing:9 pmDuration:2 hours

Other Forms:

20mg or 40mg powder and solvent for solution for injection

Indications: short term treatment of postoperative pain

Mechanism of Action:By inhibition of both peripheral and central COX-2, valdecoxib reduces the production ofprostaglandins that are important mediators of pain and inflammation.

Adverse effects:Nausea, abdominal pain, headache, abdominal fullness, dizziness, back pain, fever, hypoactive bowel sounds, vomiting, tachycardia, somnolence, abnor mal breath sounds and pruritus Interactions:No known drug interactions

-observe the 5 rights to medications-assess v/s every 4 hours

-assess patient condition before and after the regimen-watch for signs of adverse reactions- Assess patients knowledge about the therapy

-for proper drug administration-to monitor v/s and watch for abnormalities-to assess drug effectiveness


- to provide information betweenknowledge gaps

-teach patient for the side effects, actions, interactions of the drug-teach patient to adhere to the doctor’s orders-advice patient not to drive because drug can cause dizziness-teach patient symptoms that needs doctors assistance

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NURSING ACTIONS


Generic Name : Nalbuphine

Brand Name:Nubain

Classification : opioid agonist-antagonist analgesic

Ordered:Give Nalbuphine(Nubain) 5mg slow IV push every 8 hours

Timing:8am, 4pm, 12 midnightDuration:

30min

Other Forms:

10 mg/mL, 10 mL multiple dose vials, 10 mg/mL, 1 mL ampules, 20 mg/mL, 10 mL multiple dose vials

Indications: relief of moderateto severe pain, supplement to balanced anesthesia, for preoperative and postoperative analgesia, and for obstetrical analgesia

Mechanism of Action:

Receptor studies show that nalbuphine exerts its action via binding to mu, kappa, and delta receptors, but not to sigma receptors. Nalbuphine HCL is primarily a kappa agonist/partial mu antagonist analgesic.

Adverse effects:

depression, restlessness, crying, Hypertension, hypotension, bradycardia, tachycardia, Cramps, dyspepsia, bitter taste

Interactions:

Patients receiving an opioid analgesic, general anesthetics, phenothiazines, or other tranquilizers, sedatives, hypnotics, or other CNS depressants (including alcohol) concomitantly with NUBAIN may exhibit an additive effect






-teach patient for the side effects, actions, interactions of the drug-teach patient to adhere to the doctor’s orders-teach patient symptoms that needs doctors assistance











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NURSING ACTIONS


Generic Name :

Etoricoxib

Brand Name:

Arcoxia

Classification : COX-2 Selective Inhibitor

Ordered:

Give Etoricoxib(Arcoxia) 120mg/tablet orally once a day

Timing:8am

Duration:2hours

Other Forms:

Tablets: 60, 90 mg tab

Indications:

Acute gout, Rheumatoid Arthritis, Osteoarthritis,

short term treatment of postoperative pain

Mechanism of Action:

Etoricoxib selectively inhibits isoform 2 of cyclo-oxigenase enzyme (COX-2). This reduces the generation of prostaglandins (PGs) from arachidonic acid hat are important mediators of pain and inflammation.

Adverse effects:fatigue and dizziness, ulceration, bleeding or perforation of the stomach or intestinal lining, increased risk of heart attacks and stroke, Excessive fluid retention in the body tissues, Dizziness,Headache,hypertension,Palpitations,diarrhoea, nausea, indigestion, flatulence or abdominal pain,Feeling weak or fatigued,Cold or flu-like symptoms.Interactions:

No known drug interactions






-teach patient for the side effects, actions, interactions of the drug-teach patient to adhere to the doctor’s orders-advice patient not to drive because drug can cause dizziness-teach patient symptoms that needs doctors assistance

http://en.wikipedia.org/wiki/Prostaglandins

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XI. NURSING MANAGEMENTNURSING CARE PLAN

PATIENT: ROOM NO. : 7A - 708 AGE: PHYSICIAN: DIAGNOSIS: FIBROCYSTIC BREAST DISEASE NURSE’S SIGNATURE:

CLINICAL PORTRAIT PERTINENT DATAI.Received patient lying on bed, conscious, responsive, coherent,afebrile, with ease in respiration. Patient is time oriented and place oriented. No dizziness or blindness was felt by the patient. Patient is with #2 D5LR regulated at 120cc/hr, infusing well at left hand.II.Significant findings: Incision on the right breast was noted.

III.Vital Signs taken during first contact:

T: 36.2C; P:76bpm; R: 17cpm; BP: 110/70mmhg

I.A case of M.L.Y. , 40 years old, female. Filipino, roman catholic, a resident of Talamban Cebu City was admitted to Chong Hua due to presence of breast lump.II.Chief complaints: Swollen and painful breast with white discharges.III.Health History:One year prior to admission patient noted right breast mass but did not sought consult so no interventions were given. 3 days prior to admission patient noted swelling of the breast with associated pain thus prompted consultIV.CLINICAL CEMISTRY REPORT (7-21-10, AT 1:28PM)TEST RESULT REFERENCECreatinine 0.8 0.6-1.5Alkaline phosphatase 40 45.5-125.0

HEMATOLOGY REPORT (7-21-10 AT 9:31PM)Result Reference UnitBleeding Time4.23 mins 2.3-9.5 Minutes

HEMATOLGY REPORT (7-21-10 AT 9:20 PM)COMPLETE BLOOD COUNT

RESULT REFERENCE•WBC 6.10 4.8-10.8•RBC 4.76 4.2-5.4•HEMOGLOBIN 11.8 12.0-16.0

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•HEMATOCRIT 36.2 37.0-47.0•PLATELET 19 130-400BLOOD INDICES•MCV 6.0 81-99•MCH 24.9 27.0-31.0•MCHC 32.7 33.0-37.0•RDW 12.1 11-16•PDW 13.8 9.0-14.0•MPV 9.1 7.2-8.11ABSOLUTE DIFFERENTIAL COUNT•NEUTROPHIL 3.59 1.9-8.0•LYMPHOCYTE 2.27 0.9-5.2•MONOCYTE 0.13 0.16-1.00•EOSINOPHILS 0.11 0.0-0.8•BASOPHILS 0.01 0.0-2

V.V/S during admission:T: 37.2Celsius P: 71bpm R: 20cpm BP: 120/70

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CUES NURSING DIAGNOSIS

SCIENTIFIC BASIS

GOALS & OBJECTIVES

NURSING ACTIONS & ORDERS

RATIONALE EVALUATION

Subjective: “and akong incision sakit jud day, maglisud ko ug ilis”-pain scale of 7/10

Objective:-noted presence of wound at the right breast-patient is observed exhibiting grimaced face every time she changes cloth-V/S : T- 36.5 P-75bpm R- 25cpm-slightly elevated respiratory rate

Altered comfort: Pain related to presence of tissue trauma

Unpleasant sensory and emotional experience arising from actual or potential tissue damage or described in terms of such damage; sudden or slow onset of any intensity from mild to severe with an anticipated or predictable end.

(Nurse’s Pocket Guide, Doenges)

After 4-8 hours of nursing intervention the patient will be relieved of pain specifically:

1.) Learn and demonstrate techniques on non pharmacological pain management

2.) report reduced pain scale of 7/10 to 4/10

Render nursing care that will help the patient be relieved of pain, specifically:

Independent-taught the patient about proper deep breathing exercise- instructed the patient to splint the wound whenever she coughs-encouraged use of loose clothing-Encouraged adequate rest periodsDependent-followed doctors orders

Independent: -assessed v/s every 4 hours

-assessed pain characteristics-provided quiet and calm environment-encourage diversional activities

-reduces pain

-reduce pain

- lessen irritation on the wound-to prevent fatigue

-for proper management of care

-to monitor any abnormalities-to know the severity of pain- to promote relaxation-to reduce precipitating

1.) Goal met: patient exhibited deep breathing every time she feels pain

2.)Goal met: Pain was reduced to 4/10 from 7/10

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3. Adhere to the drug regimen

Dependent:-administered Dynastat 40 mg IVTT

Independent-explained the actions and side effects of the drug

-Provided a list of patient’s medications

Dependent:

-administered Arcoxia (etoricoxib)

factors

-to provide pharmacological management of pain- to exercise patient’s right to be informed- to make the patient aware of her medications

- to provide pharmacological management

3. Goal met: patient receive the correct drug and adhered to the regimen

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SCIENTIFIC BASIS

GOALS & OBJECTIVES



Subjective: “ang akong incision, sakit jud day, maglisud ko ug ilis”


Risk for infection related to inadequate primary defenses AEB presence of incision at the right breast

At increased risk for being invaded by pathogenic organisms when the body’s defenses are being compromised ( tissue trauma, decreased immune system function)


After 3-5 hours of nursing interventions the patient will be able to demonstrate infection control, specifically:

1. Patient shall verbalize an understanding of the risk factors of infection

2. Patient's surgical incision will remain free from infection during her stay

Independent-explained to the patient that presence of wound may cause infection-taught of proper techniques of preventing infection.-encourage hand washing among the SO-taught patient the cardinal signs and symptoms of infection and have the patient "assist" in his / her own wound assessment before discharge

Independent- assessed the clients knowledge of infection

- taught the patient proper hand washing techniques

-to provide knowledge of the health condition-to reduce risk for infection

-to reduce risk for infection-

- provides baseline for future teaching

- promotes active participation and

Goal met: Patient understood about her condition

Goal met: Patient is free from infection

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and clean dressing change techniques

-Observe and report signs of infection such as redness, warmth, discharge, and increased body temperature.-kept the dressing dry, clean,and intact

-assessed V/S every 4 hours

Dependent-administered Paracetamol Tylenol for temperatire of 38 celsius

Collaborative-collaborate for the dietician to give patient high protein diet

a patient teaching opportunity.-to provide intermediate intervention and prevent progress of infection- to keep the physical barrier intact and prevent infection-to monitor V/S

-to provide pharmacological management

-for faster healing

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SCIENTIFIC BASIS

GOALS & OBJECTIVES



Subjective: “ang akong incision, sakit jud day, maglisud ko ug ilis”


Impaired skin integrity related to tissue trauma secondary to surgical incision at the right breast

A state in which the individual’s skin is adversely altered, disruption, or break in the skin, from its normal anatomy that extends through the two top layers of the skin, the dermis and epidermis.


After 83-5 hours of nursing interventions the patient will be able to demonstrate improvement of wound healing, specifically:

1.) Verbalize understanding of techniques for faster wound healing

Independent

-taught patient to eat high protein meals

-encouraged frequent hand washing

-explained about the health condition of the patient

-taught about the importance of healthy diet and lifestyle- Emphasized importance of adequate nutrition and fluid intake

-promotes faster healing of tissues

-to prevent infection

-to provide knowledge about the condition-healthy diet and lifestyle prevents lump formations- improved nutritionand hydration willimproveskincondition

Goal met:Verbalized understanding of faster wound healing and showed interest in infection control

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2.) demonstrate preventive behaviors for infection

Independent-instruct patient to change dressings regularly

-taught for signs of infection

-taught and demonstrated to the patient for proper wound care

-assessed v/s every 4 hours

Collaborative-team up with the dietician to give the patient appropriate diet

-to prevent infection and faster healing

-to reduce risk for infection

- Cleaning the woundwill minimize the riskfor infection andswelling thus promotes healing- to monitor v/s and provide interventions for abnormalities

-for faster wound healing

Goal met: Demonstrated preventive behaviors for infection

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DISCHARGE PLANPATIENT: M.L.Y. ROOM NO. : 7A -708 AGE: 40 years old PHYSICIAN: DR. CRISOSTOMO DYDIAGNOSIS: FIBROCYSTIC BREAST DISEASE NURSE’S SIGNATURE:

PATIENT’S OUTCOME CRITERIA NURSING ORDERS

As soon as the patient is discharged from the hospital, the patient and the significant others will be able to acquire basic knowledge, develop beginning skills and positive attitude.

Specifically, the patient and the significant others will be able to:

ASSESSMENT

1. Assess vital signs with the help of the significant others.

2. Monitor condition.

3. Assess for presence of support persons & adequacy of family resources in the care of the patient.

4.5. Perform self breast examination

PLANNING

1. Plan ahead the return visit to the physi-cian’s clinic or hospital.

2. Make a chart/note for the improvement of the condition of the patient.

IMPLEMENTATION

1.1 Follow the correct schedule and dosage in taking medication.

Teach significant others in getting the vital signs.

Encourage significant others to observe the condition of the patient and refer if any unnecessary things occurs.

Discuss with the family the importance of helping out in the care of the patient especially at home.

Discuss about breast examinations and its importance

Remind the patient and the significant others to reserve schedule for follow-up check-up for monitoring the status.

Encourage the patient and the significant others to make a chart to monitor the progress of the condition.

Tell the patient and the significant others the importance of following the correct schedule and dosage in taking the medications.

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1.2 Never skip taking maintenance medi-cation.

1.3 Follow guidelines or measures before and after taking the medications.

1.4 Comply with the medication regimen.

2.1 Exercise only to the prescribed dura-tion and intensity.

2.2 Rest in between figures of exercises.

3.1 Comply with medication and follow-up check-ups.

4.1 Instruct to practice proper hygiene.

4.2 Recommend limiting intake of caffeine and alcoholic beverages.

5.1 Take on regular visit to hospital for consultation and counseling.

6.1 Follow dietary regimen as prescribed by the dietitian.

EVALUATION

1. Evaluate self- compliance of the whole treatment regimen.

2. Evaluate progress of client’s condition.

Tell the family members not to fail the patient from taking the medications for this will disrupt the continuity of treatment and follow correct procedure in taking the medications.

Inform the patient and the significant others the importance of following guidelines of certain medication.

Encourage the patient to follow medication regimen as prescribed.

Teach family the measures on what is the allowed exercise for the patient.

Emphasize the importance of rest in between exercise to compensate for oxygen needs.

Explain to the patient and the significant others its importance and it allows understanding in complying the treatment regimen.

To promote comfort and prevention of the transmission of bacterial microorganism.

To prevent complications.

Discuss to the patient the importance of regular check-ups to the hospital.

Inform the family about the food that promotes good nutritional diet that fits for the patient.

Emphasize the importance of complying and evaluating to monitor patient’s condition.

Encourage the client and the family to evaluate the progress of the patient’s condition.

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XII. CONCLUSIONS AND RECOMMENDATIONS

CONCLUSIONS

Therefore, I conclude that early diagnosis is important so that complications can be prevented. Breast

self exam should be widely implemented to have early detections of benign or malignant lumps. And,

women with unhealthy lifestyle are more prone to developing breast lumps.

RECOMMENDATIONS

I recommend that a wide health teaching about breast self exam wil be implemented. And that the other

levels in nursing will study more about this diagnosis and give more information about the diagnosis

and prevention of this disease.

XIII. IMPLICATION OF THE STUDY TO:

NURSING EDUCATION

This study stressed the importance of the concept in giving optimal care. Being health educator, and

student, we should be able to realize that handling patients does not only require our physical capacities

but also our concern and understanding. Knowledge about care should be widened and broadened to

have a more satisfying effect on the patient. For our knowledge together with our attitude and skills are

great dynamics for high-quality care for our patients. Continuing education for ourselves will be helpful

so that we can give further information to our client about Fibrocystic Breast Disease and other

diseases.

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NURSING PRACTICE

Study is centered on providing the best possible care for our patients. Knowledge should always go

with skills which is essential in performance of the procedures with one goal which is to help patients

go back to their wellness state of being. This study can provide additional information about

understanding patients’ condition. And can help us more in giving interventions to patients who are ill

and lack of knowledge about the disease.

NURSING RESEARCH

This study can serve as a guide for our researchers in the future to be used as base of information.

Conducting more studies related to this would allow more information to be gathered, and more

problems to be discovered with their own means of being resolved.

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APPENDICES

35

APPENDIX

A

37

BIBIOGRAPHY

Books:

Doenges, Marielyn E., et. al. (2006) Nursing Care Plans, Guidelines for Individualizing Patient Care.

(7th Edition)

Doenges, Marielyn E., et. al. (2006). Nurse’s Pocket Guide. (10th Edition)

Kozier, Barbara et. al. (2004). Fundamentals of Nursing, Concepts, Process and Practice. (7th Edition)

Delaune, Sue C. et. al. (2006). Fundamentals of Nursing, Standards & Practice. (3rd Edition)

Seeley, Rod R. et. al. (2007). Essentials of Anatomy and Physiology. (6th Edition).

Smeltzer, Suzanne C. et. al. (2010). Textbook of Medical-Surgical Nursing. (12th Edition).

Karch, Amy A. et. al. (2009). Lippincotts’s Nursing Drug Guide.

Lippincott Williams & Wilkins et. al. (200). Student Drug Handbook.

Internet:

http://www.medicinenet.com/fibrocystic_breast_condition/article.htm

http://www.umm.edu/ency/article/000912.htm

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