St.

Paul University Philippines

Tuguegarao City, Cagayan 3500

Graduate School

ADVANCE ADULT HEALTH NURSING 2

MASTERS OF SCIENCE IN NURSING

NAME: DANICA LORINE R. TAGUINOD

COURSE: MSN-ADULT HEALTH

CASE STUDY
BREAST CANCER

1.PATIENTS PROFILE:
E.V.B is a 62y/o female, married with 2 children from Pasig City, Metro Manila with a
diagnosis of invasive ductal carcinoma,Nottingham histologic grade 2.

Personal History:
Non-smoker, non-alcoholic drinker, at menopausal stage

Family History:
Two of her auntie’s died of Cancer specifically lung cancer

2. BRIEF DISCUSSION OF THE CASE:

History of Present Illness:

3 months PTC patient experienced severe pain at the left breast, no consult done.
With persistent pain, patient did breast self examination and revealed a mass under the
nipple, hence medical consult had been made.

Upon consult, patient underwent ultrasound which revealed tumour mass size 0.6cm ,
hence lumpectomy were advised following biopsy. The biopsy confirmed invasive
ductal and papillary carcinoma ,Nottingham histologic grade 2.
Upon knowing the result, patient was scheduled for modified radical mastectomy.
After surgery, patient had undergone hormonal therapy of Levotrozole 2.5 mg once
daily for 5 years. 2 weeks after mastectomy, CA15 test results is within normal range.

2. INCIDENCE OF BREAST CANCER IN THE PHILIPPINES

Among Filipino women the 6 most common sites diagnosed were

breast, cervix, lung, colon/rectum, ovary and liver.  Furthermore, 189 of
every 100,000 Filipinos are afflicted with cancer while four Filipinos die of
cancer every hour or 96 cancer patients every day, according to a study
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conducted by the University of the Philippines’ Institute of Human Genetics,

National Institutes of Health.
Breast cancer originates from the breast tissue that starts from the milk ducts or
the lobules that supplies the ducts with milk. It is the most common cancer
among women worldwide in which 18.2% of all cancer deaths are accounted
to breast cancer. Among Asian countries, the Philippines ranks first on
having lowest survival rate of people with breast cancer.It is said that 3 out of
100 Filipino women will get breast cancer before age 75 and one out of 100
will die before reaching theage of 75.
According to the 2015 Philippine Cancer Facts and Estimates, breast cancer is the
most common (20,267 cases) and the 3rd leading cause of cancer-related
deaths (7,384 cases) among the Filipinos, next to lung and liver cancer.
Cancer is a result of complex mix of factors related to heredity, diet,
physical inactivity and prolonged, continuous exposure to certain chemicals
and other substances. Several factors that increase a person’s chance of
developing cancer has been identified and are called “risk factors”. Diet
plays an important role in the development of many cancers, particularly in
the digestive and reproductive organs. Long-term habit of not eating a
healthy diet has been linked that increases incidence of cancer. Likewise,
being seriously overweight has been linked to breast cancer.

3. . NURSING ASSESSMENT (GORDON’S FUNCTIONAL ASSESSMENT)

 
PATTERN BEFORE HOSPITALIZATION DURING HOSPITALIZATION
     
  The patient defines as health is being free The patient consider herself as unhealthy. She
 Health Perception and Health from any diseases or illnesses. She also is not working anymore because she feels that
Management Pattern  stated that before she works as a factory she is not capable to do heavy works already.
worker in Manila. She is just staying at home for now and just do
common household chores.
 
     
  The patient stated that she eats her meal Patient said that she has loss her appetite,
 Nutrition and Metabolism three times a day and have snack in the especially after her chemotherapy. She only
Pattern morning and afternoon. She eats vegetables, eats small amount of food and trying to avoid
meat, fish, beef and even processed foods. eating processed foods.
 
     
  She was able to urinate 5-6 times a day and She said that there is less frequency in
 Elimination Pattern defecate once a day, most probably in the urinating, approximately 3-4 times a day and
morning before going to work. defecate once a day and sometimes every
  other day.
 
     
 Activity and Exercise Pattern She was working in a factory and after work She does household chores like cooking,
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she do walking as a part of her daily washing dishes and clothes and cleaning their
routine. house. She also does gardening as her past
  time. Still walking as her exercise.
 
     
 Sleep and Rest Pattern The patient has normal cycles of sleep. She She prefers to sleep 8-9 hours a day and have
sleeps 6-8 hours a day. a nap in the afternoon. She wants to take a rest
  in 3 days’ time every after her chemotherapy.
 
     
     
  The patient stated that she was a high The same as before hospitalization. The
 Cognition and school graduate and able to read and memory is still intact. She understands what
Perception Pattern write. The patient is conscious, coherent, her condition was.
and oriented to time.
     
  She describes herself as functional. She She said that her self-concept was altered.
 Self-Perception and Self- mentioned an example like she was earning Sometimes, she thinks that she is burden to
Concept Pattern for her family to help and sustain their daily her family because of her illness and
needs. She also views herself as optimistic she cannot help to sustain their daily needs.
and confident person.
 
     
 Roles and Relationships Pattern She stated that she is single. She is fifth of She said that the bonding of their family is
her six siblings and one of the bread still intact and even more because of her
winners in their family.They have an intact condition. She is supported by her family
relationship with their family. especially for her treatment. 
   
     
 Sexuality and The patient said that she is single and She stated that when she came home here in
Reproduction Pattern admitted that have an affair with same sex Cagayan, she is no longer with her partner, but
of her(girl), in other words she claimed that they are still friends and have communication.
she is lesbian. They live together when she
is still working in Manila.
 
     
  The patient stated that in times of stress or She said that the same perception she has,
10. Coping and Stress trials, she usually tackles with her partner, only that it is her familywhom she tackles
Tolerance Pattern and they solve together and believes that her problems,and they discuss, solve, and
everything will be alright as she is prays together.
optimistic in life.
 
     
11. Values and Belief Pattern She stated that she is Roman Catholic and The same beliefs she had but her faith to God
believes that God is with her in all trials or became deeper and entrust to him everything
problems that she has. She attends mass but especially now because of her condition. She
not regularly.  attends mass regularly every Sunday.
 
 

IV. ANATOMY AND PHYSIOLOGY

 
Women and men both have breasts, but women have more breast tissue
than men. The breasts contain mammary glands. Only the mammary glands in
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women can make milk to feed a baby. For this reason, the breasts are
accessory organs of the female reproductive system.
 

The breasts are divided by an invisible line running up and down and right to
left through the nipple. Each of these 4 regions is called a quadrant. Most breast
cancers develop in the upper outer quadrant of the breast, closest to the armpit.
This is because this area has a lot of glandular tissue.
 
STRUCTURE:
 
Each breast lies over a muscle of the chest called the pectoral muscle.
The female breast covers a fairly large area. It extends from just below the
collarbone (clavicle), to the armpit (axilla) and across to the breastbone
(sternum).
 
 
1. PECTORAL MUSCLE (CHEST MUSCLE)- each of the four large, paired
muscles that cover the front of the rib cage and serve to draw the forelimbs toward
the chest.
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2. CLAVICLE(COLLARBONE)- the bone that runs horizontally between the top
of your breastbone (sternum) and shoulder blade (scapula). You can feel
your collarbone by touching the area between your neck and your shoulder.
 
3. AXILLA(ARMPIT)- the cavity beneath the junction of the arm or anterior
appendage and shoulder or shoulder girdle containing the axillary artery and vein,
a part of the brachial plexus of nerves, many lymph nodes, and fat and areolar
tissue. 
 
4. STERNUM (BREASTBONE)- the long flat bone in the upper middle of the front
of the chest. The sternum articulates with the cartilages of the first seven ribs and
with the clavicle on either side.
 
PARTS OF THE BREAST:
 
 
 
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The breast is made up of fat, connective tissue, glands, and ducts.

 
1. LIGAMENTS are dense bands of connective tissue that support the breast. They
run from the skin through the breast and attach to muscles on the chest.
 
2. LOBULES are the groups of glands that make milk. There are 15–25 lobules in
each breast. The glands make milk when they are stimulated by hormones in a
woman’s body during pregnancy.
 
3. DUCTS are tubes that carry milk from the lobules to the nipple.
 
4. NIPPLE is the area at the center of the areola with an opening to release
milk. The nipples contain muscle fibers. When these muscle fibers contract,
the nipple becomes erect, or pointed outward.
 
5. AREOLA is the pink or brown, circular area around the nipple on the surface of
the breast. It contains small glands that release, or secrete, an oily substance that
acts as a lubricant for the nipple and areola.
 
 
THE LYMPHATIC SYSTEM OF THE BREAST
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The breast has many blood vessels and lymph vessels. Lymph vessels are thin
tubes like blood vessels. They collect and move lymph fluid away from the
breast into small bean-shaped masses of lymphatic tissue (called lymph
nodes) around the breast. The lymph vessels and lymph nodes are part of
the lymphatic system, which helps fight infections.
 
BREAST LYMPH NODES:
 
1. SUPRACLAVICULAR LYMPH NODES are above the collarbone.
 
2. INFRACLAVICULAR LYMPH NODES are below the collarbone.
 
3. INTERNAL MAMMARY LYMPH NODES are inside the chest around the
breastbone (called sternum).
 
4. AXILLARY LYMPH NODES are under the arm (called the axilla). There are
about 30–50 lymph nodes in the axilla. They are divided into 3 levels based on
how close they are to the large 
 

PATHOPHYSIOLOGY

Predisposing Precipitating
factors: factors:
62 y/o female,
LATE HISTORY OF
MENOPAUSAL ABNORMAL
BREAST BIOPSIES

Neoplasm
formation in the
breast

Primary tumor
begins in the
breast
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LABORATORY FINDINGS
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VII. NURSING CARE PLAN (3 Priority Nursing Diagnosis)

 
 
Patient’s Name: EVB            Sex: Female
Age: 62 y/o

NURSING CARE PLAN

 
ASSESSMENT NURSIN PLANNING INTERVENTIO RATIONALE EVALUATION
G N
DIAGNO
S
           
SUBJECTIVE: Acute Pain After 1 hour of nursing  Monitor vital ✓ To obtain Goal met. After 1
“Kumikirot yung r/t Left interventions, the patient will be signs. patient’sbaseline hour of nursing
kaliwang dibdib Breast able to:   data. interventions, the
ko.parang may Mass       patient was able to:
tumutusok” enlargeme Verbalize relief of pain.   ✓ Information  
  nt    Determine pain provides  
OBJECTIVE:  Present history (location baseline data to 1. Verbalize
▪ Grimaced face improvement of facialexpression. of pain, evaluate reduction of pain
▪ Frequentchange of   frequency, effectiveness of from 7/10 to 3/10.
position   duration, and interventions.  
▪ Irritable  Enumerate non-pharmacologic intensity using   2. Present
pain relief strategies. numeric rating   improvement of
scale (0-10 scale).   facial expression as
    manifested bysmiling
and decreased muscle
  ✓ Pharmacologic
guarding.
 Administer due way to reduce
medications as pain.  
ordered by the 3. Enumerate non-
physician. pharmacologic ways
to relieve pain
(diversional
activities,
massage, repositionin
g, backrub).
 
 
 
ASSESSMENT NURSING PLANNING INTERVENTION RATIONALE EVALUATION
DIAGNOS
           
SUBJECTIVE Imbalanced Within 6-8 hours of  Monitor daily food✓ Identifies Goal met. After 6-
“ wala akong Nutrition: nursing interventions, the intake. nutritional 8 hours of nursing
ganang kumain” Less Than patient will be able to:   strengths and interventions, the patient
  Body     deficiencies. was able to:
OBJECTIVE: Requiremt 1. Verbalizeunderstanding of      
▪ Decreased individual interferences to Weigh patient daily.
✓ To assess  
subcutaneous adequate intake. Record intake and adequacy of diet.  1. Verbalize understanding
fat/muscles.   output.   of individual interferences
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▪ Loss of appetite 2. Participate in     to adequate intake.

▪ Weakness of specificinterventions to  Assess skin and ✓ Helps in  
muscles (weak stimulate appetite/increase mucous membranes identification of 2. Participate
to move) dietary intake. for pallor. protein-calorie specific interventions to
▪ Dry mouth     malnutrition and stimulate appetite.
3. Increase oral intake.   fluid intake.  
       
4. Demonstrate healthy oral      
mucous membrane.  Encourage use of    
✓ Supplements
food supplements. can 3. Increase oral intake as
  play an important recorded.
  role in  
  maintaining 4. Demonstrate healthy
  adequatecaloric oral mucous membrane
  and protein intake. (lips is not dry)
      
     
 
 
ASSESSMENT NURSING PLANNING INTERVENTION RATIONALE EVALUATION
DIAGNOS
         
SUBJECTIVE: Fatigue r/t After 8 hoursof  Monitorphysiological ✓ Tolerance varies
“Nanghihina ako Altered Body nursing response to activity greatly depending on
lagi” Chemistry: interventions, the (changes in BP, heart, and the stage of disease
  Side Effects of patient will be able respiratory rate. process, nutrition state,
OBJECTIVE: Pain and toreport improved   fluid balance, and
▪ Lack of energy therapy sense of energy.   reaction to therapeutic
▪ Disinterest in     regimen.
surroundings    
▪ Lethargy ✓ Adequate intake of
 Encourage nutritional intake.
  nutrients is necessary to
  meet energy needs and
  build energy reserves
  for activity.
   
  ✓ Enhances strength and
 Encourage patient to do enables patient to
whatever possible and become more active
increase activity level as without undue fatigue.
tolerated.  
   
 
 

DRUG STUDY

DRUG STUDY
DRUG MECHANISM OF INDICATION CONTRAINDICATIO ADVERSE EFFECT NURSING
ACTION N RESPONSIBILITIES
           
GENERIC NAME: ➢ Inhibits ➢ Short term ➢ Contraindicated in CNS: ➢ Consider the 10 Patient’s
Ketorolac Tromethamine prostaglandin management of patients hypersensitive Drowsiness, rights of administering
  synthesis, producing moderately to drug. abnormal thinking, medications.
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BRAND NAME: peripherally severe and acute   dizziness, euphoria,  

Toradol mediated analgesia. pain (not to ➢ Use cautiously in: headache ➢ Assess pain (note type,
  It has also exceed 5 days     location, and intensity) prior
CLASSIFICATION: antipyretic and anti- continued • Cardiovascular disease Respiratory:Asthm to 1-2 hours following
NSAID (Non-Steroidal inflammatory use). or risk factors for a, dyspnea administration.
Anti-Inflammatory properties cardiovascular disease    
Drug), Nonopiod Analgesi (may increase risk of CV:
➢ Assess for signs of drug
c serious cardiovascular Edema, pallor,
reactions.
  thrombotic events, vasodilation
DOSAGE: myocardial infarction,  
30mg/IV every 6 hours and stroke, especially GI: 
with prolonged use. GI bleeding,
  abnormal taste,
• History of GI bleeding. diarrhea, dry mouth,
dyspepsia, GI pain,
 
nausea
• Renal impairment
 
(dosage reduction may
GU:
be required)
Oliguria, renal
  toxicity, urinary
  frequency
 
Dermatologic:
Exfoliative,
dermatitis, Steven’s
Johnson Syndrome,
toxic necrolysis,
pruritus, sweating,
urticaria
 
Hematology:
Prolonged bleeding
. time
 
Neurology:
Paresthesia

Cefuroxime binds Oral

to one or more of (cefuroxime Hypersensitivity to
Generic Name: the penicillin- axetil) cephalosporins
cefuroxime, cefuroxime binding proteins >Large doses can
.>Pharyngitis, Assessment
axetil, cefuroxime sodium (PBPs) which cause cerebral
inhibits the final tonsillitis irritation and
History: Hepatic and renal
Brand Name: transpeptidation caused convulsions; nausea,
by Streptococcu impairment, lactation,
Ceftin , Zinacef step of vomiting, diarrhea,
s pyogenes pregnancy
peptidoglycan GI disturbances;
>Otitis media Physical: Skin status,
Classification: synthesis in erythema
caused LFTs, renal function tests,
Antibiotic, Cephalosporin bacterial cell multiforme, Stevens-
by Streptococcu culture of affected area,
(second generation) wall, thus Johnson syndrome,
s pneumoniae, sensitivity tests
inhibiting epidermal
Interventions
biosynthesis and S. pyogenes, necrolysis.
Surgical prophylaxis 1.5 g arresting cell wall Haemophilus Potentially Fatal:
influenzae, Culture infection, and
IV per-op, then 750 mg assembly Anaphylaxis,
Moraxella arrange for sensitivity
IM 8 hrly for up to 24-48 resulting in nephrotoxicity,
catarrhalis tests before and during
hr. Susceptible bacterial cell pseudomembranous
>Lower therapy if expected
infections750 mg 8 hrly, death. colitis.
respiratory response is not seen.
up to 1.5 g 6-8 hrly for Absorption:
Give oral drug with food
severe infections. Absorbed from infections
to decrease GI upset and
the GI tract with caused by S.
pneumoniae, enhance absorption.
peak plasma
Haemophilus Give oral drug to children
concentrations
who can swallow tablets;
after 2-3 hr (oral); parainfluenzae,
crushing the drug results
may be enhanced H. influenzae
in a bitter, unpleasant
by the presence >UTIs caused
by Escherichia taste.
of food.
coli, Klebsiella Have vitamin K available
Distribution:
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Pleural and pneumoniae in case

synovial fluid, >Uncomplicate hypoprothrombinemia
sputum, bone and d gonorrhea occurs.
aqueous fluids; (urethral and Discontinue if
CSF (therapeutic endocervical) hypersensitivity reaction
concentrations). >Dermatologic occurs.
Crosses the infections, Teaching points
placenta and including
enters breast impetigo caused Oral drug
milk. Protein- by Streptococcu
binding: Up to s aureus, S. Take full course of
50%. pyogenes therapy even if you are
Metabolism: >Treatment of feeling better.
Rapidly early Lyme This drug is specific for
hydrolysed disease this infection and should
(intestinal Parenteral not be used to self-treat
mucosa and (cefuroxime other problems.
blood). sodium)  Swallow tablets whole; do
Excretion: Via the >Lower not crush them. Take the
urine by glomerular respiratory drug with food.
filtration and renal infections You may experience these
tubular secretion (ascaused by S. side effects: Stomach
unchanged); via bile pneumoniae, S. upset or diarrhea.
(small amounts); 70 aureus, E. coli, Report severe diarrhea
min (elimination Klebsiella, H. with blood, pus, or mucus;
half-life); prolongedinfluenzae, S. rash; difficulty breathing;
in neonates and pyogenes unusual tiredness, fatigue;
renal impairment >Dermatologic unusual bleeding or
infections bruising; unusual itching
caused by S. or irritation.
aureus, S. Parenteral drug
pyogenes, E.
coli, Klebsiella, Avoid alcohol while
Enterobacter taking this drug and for 3
>UTIs caused days after because severe
by E. coli, reactions often occur.
Klebsiella You may experience these
>Uncomplicate side effects: Stomach
d and upset or diarrhea.
disseminated Report severe diarrhea,
gonorrhea difficulty breathing, unusual
caused by N. tiredness or fatigue, pain at
gonorrhoeae injection site.
>Septicemia
caused by S.
pneumoniae, S.
aureus, E. coli,
Klebsiella, H.
influenzae
>Meningitis
caused by S.
pneumoniae, H.
influenzae, S.
aureus, N.
meningitidis
>Bone and joint
infections
caused by S.
aureus Assessment
>Perioperative
prophylaxis History: Hypersensitivity
Gabapentin is >Treatment of to gabapentin; lactation,
structurally related acute bacterial pregnancy
to the maxillary Physical: Weight; T; skin
neurotransmitter sinusitis in color, lesions; orientation,
GABA but is neither patients 3 mo– affect, reflexes; P; R,
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a GABA agonist nor 12 yr adventitious sounds;

antagonist. Hypersensitivity. bowel sounds, normal
Gabapentin-binding Lactation. output
sites have been Interventions
identified Adjunctive
throughout the brain therapy in the  Somnolence, Give drug with food to
tissues e.g. treatment of dizziness, ataxia, prevent GI upset.
Generic Name : neocortex and partial seizures weakness, Arrange for consultation
gabapentin hippocampus. with and paraesthesia, fatigue, with support groups for
However, the exact without headache; people with epilepsy.
Brand Name: Apo- mechanism of action secondary nystagmus, diplopia; WARNING: If overdose
Gabapentin (CAN), Gen- is still unknown.. generalization nausea, vomiting, wt occurs, hemodialysis may
Gabapentin (CAN), in adults and gain, dyspepsia; be an option.
Neurontin children 3–12 yr rhinitis; tremor; Teaching points
with epilepsy leucopenia; altered
Classification: Orphan drug LFTs; Stevens- Take this drug exactly as
Antiepileptic use: Treatment Johnson syndrome. prescribed; do not
of amyotrophic discontinue abruptly or
Pregnancy Category C lateral sclerosis change dosage, except on
Management of the advice of your health
ADULTS postherpetic care provider.
neuralgia or Wear a medical alert ID at
Epilepsy: Starting dose is pain in the area all times so that any
300 mg PO tid, then affected by emergency medical
titrated up as needed. herpes zoster personnel will know that
Maintenance: 900–1,800 after the disease you have epilepsy and are
mg/day PO in divided has been treated taking antiepileptic
doses tid PO; maximum Unlabeled uses: medication.
interval between doses Tremors of MS, You may experience these
should not exceed 12 hr. neuropathic side effects: Dizziness,
Up to 2,400–3,600 mg/day pain, bipolar blurred vision (avoid
has been used. disorder, driving or performing
Postherpetic neuralgia: migraine other tasks requiring
Initial dose of 300 mg/day prophylaxis alertness or visual acuity);
PO; 300 mg bid PO on GI upset (take drug with
day 2; 300 mg tid PO on food or milk, eat frequent
day 3. small meals); headache,
nervousness, insomnia;
fatigue (periodic rest
periods may help).
Report severe headache,
sleepwalking, rash, severe
vomiting, chills, fever,
difficulty breathing.

: Nurses evaluating the use

of letrozole should do the
following. • Assess
menopausal status of
patients with
breast cancer. Therapy
with aromatase in- hibitors
alone does not suppress
estrogen production
adequately in women who
are still ovulating.
• Assess patients for
history of thromboem-
Letrozole is a bolism and liver or renal
competitive inhibi- insufficiency.
tor of aromatase that • Review patients’ current
blocks the medications
conversion of (prescription and
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androgens into nonprescription, includ-

estrogens, thus ing vitamins and herbs).
lowering the amount Letrozole is contrain- • Monitor patients’ vital
of estrogen in the dicated in patients with signs, with ongo-
bloodstream. This known hypersensi- ing assessment of blood
then restricts the tivity to the drug/class pressure.
supply of estrogen or components. Cau- • Inform patients that an
to can- cers, such as Letrozole is tion should be used assistance pro- gram and
some breast cancers. indicated for when administering reimbursement
In post- menopausal treating letrozole to patients information are available
Drug name: women, estrogens advanced breast with impaired liver or by calling 800-282-7630.
Letrozole is marketed by are derived mainly cancer in post- re- nal function. The (A trial script voucher
the trade name Femara® from the action of menopausal drug may cause fetal program also is avail-
(Novartis Pharmaceu- the aromatase en- women. The harm when able).
ticals Corporation, East zyme drug is administered to • Assess for side effects.
Hanover, NJ). considered a pregnant women. The most severe
Classification: Hormone first-line is thromboembolism.
oncological. Letrozole is a treatment of Patient education: Patients
third-generation aromatase hormone receiving letrozole should
in- hibitor. receptor be taught the following.
Aminoglutethimide is an positive or •
example of a first- unknown, ••
generation aromatase locally Take letrozole as directed,
inhibitor advanced, or with or with- out food.
metastatic For gastrointestinal upset, eat
breast cancer. small meals. Report chest
In an open pain, palpitations, shortness
label,
multicenter,
randomized,
phase IIIb/IV
trial published
in European
Journal of
Cancer,
letrozole
demonstrated
higher activity
than anastrozole
(Arimidex®,
AstraZeneca .
Pharmaceuticals
LP, Wilming-
ton, DE) as a
second-line
therapy for ad-
vanced breast
cancer after
failure of
tamoxi- fen
(Rose et al.,
2003).
New England
Journal of
Medicine re-
cently published
results of a
randomized
trial, led by the
National Cancer
Institute of
Canada on
behalf of
several
cooperative
groups and the
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pharmaceutical
company,
concluding that
taking letrozole
therapy for at
least 2.4 years,
after the
completion of
standard
tamoxifen (5
years),
significantly
improves
disease-free
survival (Goss
et al., 2003).
The optimal
duration of
treatment and
long-term
toxicities has
not been estab-
lished. Because
of the
preliminary
findings, this
trial was
terminated
early, thus
leaving
a follow-up
period that was
exceptionally
short (2.4 years)
(Bryant &
Wolmark, 2003;
Burstein, 2003).