Case Study about de medical Center "Touching Lives". US

1. CASE STUDY
KAREN CAMPOS
ANA CUEVAS
MELISSA LARRAHONDO
ANGÉLICA SALCEDO

2. TABLE OF CONTENTS
ACTIVITY DURING TIME
1. Word party 15 minutes
2. Case Study – Patient
presentation
20 minutes
3. Nursing Care Plan 15 minutes

4. Introduction (patient and problem)
• Name: ROSA IRIGOYEN
• Age: 52 years
• Place of Birth: Born in Medellín, Colombia
• Place of residence: Live in Bogotá D.C.
• Marital Status: Married
• Profession: Lawyer and works in the Attorney General's Office

5. Introduction (patient and problem)
The role of the nurse will consist first of all:
• Perform a mental health assessment
• Design a nursing care plan
• The nurse performs an accompaniment

6. PROBLEM
"For two months I have seen that near the right breast in the armpit, I feel a
hard mass, which does not move and also the nipple is peeling and is
sunken."
After performing the diagnostic means: tumor marker, PET positron emission
tomography and the paraclinics. Metastasis - breast cancer Stage T2.
Introduction (patient and problem)

7. RISK FACTORS
• Promiscuity of the couple
• Infection by human
papilloma virus HVP
• Other sexually transmitted
diseases

9. How your breasts
normally look and feel
New lump or mass
Hard mass that has
irregular edges
Nipple
retraction
Redness,
scaliness or
thickening of
the nipple
Nipple
discharge

10. HISTORY
Hysterectomy and
annecetomy on
November 12, 2015.
No allergy to
medications.
Two pregnancies a
curattage a
cesarean in 1994
Infection for HPV in
1999.

11. HISTORY
No smoker or consumer
of alcoholic beverages.
Her grandmother,
her father and her
mother is healthy.
Neoplastic lesion in the u
terus, chemotherapy trea
tment was started with Ci
splatin and
5Fu Fluorouracil

12. NURSING PHYSICAL
ASSESSMENT
VITAL SIGNS
Blood Pressure 120/70 mmHg
Pulse Rate 72 x’
Respiration Rate 24 x’
Temperature 36.5°C
Oxygen saturation 98%

13. RELATED TREATMENTS

15. NURSING CARE PLAN

16. Nursing Diagnosis
• Anxiety related to change in health
status
• Body image disorder related to
disease

17. INTERVENTIONS
Orientation and verbalization about the changes caused by the
disease and surgery.
Guidance on self-acceptance of body image
Orientation so that the patient once she leaves she is
integrated to the activities of the family and with it to
avoid the social isolation
Provide assistance so that she could identify other actions
that she can implement to improve her physical image.
Identification of support groups.

18. EVALUATION
The patient had an improvement in her knowledge and
orientation about breast cancer.
The patient recognizes both physical and psychological
changes produced by the disease and treatment.
The patient recognizes the importance of self-acceptance of
body image and strengthening self-esteem and coping.