RM. is a 68-year-old white female who went to her healthcare provider with a complaint of “feeling tightness” around a lump in her right breast. She has a history of hypertension a
nursing case study
RM. is a 68-year-old white female who went to her healthcare provider with a complaint of “feeling tightness” around a lump in her right breast. She has a history of hypertension and smoking (25 pack-year)
Subjective Data
??Has a family history of breast cancer-one sister recently had lumpectomy and radiation therapy. Mother and aunt died from breast cancer when they were in their 60s.?
??Has had history of “lumpy” breasts but this lump feels different?
??Says she cannot quit smoking because of all of the stress in her life. Her husband recently left herand she has not seen her two daughters in more than six months.
??She spends most of her time watching TV.
Objective Data
Physical Examination
??59?, 205 lb.
??Blood pressure 165/100, pulse 76, respirations 20, temperature 98.8? F
??Palpable mass in right breast in upper outer quadrant
Diagnostic Studies
??Bilateral mammogram and ultrasound of right breast
Case Study Progress
R.M. goes to her follow-up visit and is told that the mammogram and ultrasound show a 4 cm mass. She
undergoes a core needle biopsy. The results indicate that the mass is infiltrating lobular carcinoma. She
undergoes a lumpectomy and axillary lymph node dissection. Six of 15 axillary lymph nodes are positive
for cancer. Two weeks after surgery, she is being seen to discuss further treatment options
Requirements:
Student Name: ____________________________ Date: ________________________ Miami Dade College Medical Campus Benjam?n Le?n School of Nursing CARE PLAN Medical Diagnosis: ____________________________________________________________________________________________________________________________________________________________ Subjective Data: ____________________________________________________________________________________________________________________________________________________________ Objective Data: ____________________________________________________________________________________________________________________________________________________________ Priority Nursing Diagnosis: ____________________________________________________________________________________________________________________________________________________________ Expected Outcome: ____________________________________________________________________________________________________________________________________________________________ Nursing Actions: *Must include assessment, interventions, and patient teaching, accompanied by rationale for doing each. Action Rationale Action Rationale
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