University of the Philippines Manila

The Health Sciences Center

COLLEGE OF NURSING
WHO Collaborating Centre for Leadership in Nursing Development
Commission on Higher Education (CHED Center for Excellence)
Sotejo Hall, Pedro Gil St., Ermita, Manila
Tel.: (632)523-1472 / Telefax: (632)523-1485

A Case Study

on

Breast Cancer Stage IV

In partial fulfillment on the requirements

In MAN- Adult Health Nursing
Cardiovascular Nursing
Philippine General Hospital
1ST Semester- 2019

Presented by:

Francis Anthony B. Losloso, RN

Presented to:

Prof. Susan Pagsibigan

Prof. Aldin Gaspar

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 Table of Contents
I. Introduction 3
II. Objectives 4
III. Nursing Health History
A. Demographic Data 5
B. Chief Complain 5
C. History of Present Illness 5
D. Past Medical History 6
E. Family History Genogram 7
F. Gordon’s Functional Health Pattern 8
IV. Review of Systems 10
V. Physical Examination 11
VI. Diagnostic and Laboratory Results 20
VII. Pathophysiology 32
VIII. Nursing Care Plan 35
IX. Drug Study 38
XI. Health Instructions 49
XII. Conclusion and Recommendations 50
XIII. References 50

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 I. Introduction:
Cancer in whatever form is terrifying especially when someone has been diagnosed
of such condition. It changes the person holistically wherein physiologic, psychosocial,
emotional and spiritual aspects of the person may be affected. According to the World
Health Organization, it is the second leading cause of death globally, and is responsible
for an estimated 9.6 million deaths in 2018, wherein 1 in 6 deaths is due to cancer.
Approximately 70% of deaths from cancer occurred in low-middle income countries
maybe due to the high-cost value of cancer treatment. Female breast cancer ranks as the
fifth leading cause of death globally having 627,000 (6.6%) deaths because the prognosis
is favorable, at least in developed countries. In the Philippines, among 106 million total
population, there were 24,798 (17.6%) new cases of breast cancer wherein all of them
are female. It is the third leading cause of mortality in the Philippines (WHO, 2018).
Cancer begins when genetic changes interfere with the normal cell division process. It
involves uncontrolled, uncoordinated and undesirable cell division and may form a mass
called tumor. These tumors may be diagnosed as benign, a tumor that does not spread
or malignant in which it spreads in different areas of the body.

Most breast cancers begin either in the breast tissue made up of glands for milk
production, called lobules, or in the ducts that connects the lobules to the nipple. The
remainder of the breast is made up of fatty, connective and lymphatic tissues. However,
there is no single, specific cause of breast cancer; rather, a combination of hormonal,
genetic and possibly environmental events may contribute to its development (Brunner &
Suddarths, 2004). Non-modifiable risk factors such as gender, age, race, genetics, early
menstruation and late menopause may contribute in the development of breast cancer. It
occurs 100 times more often in women than in men wherein two out of three women with
invasive cancers are diagnosed after the age of 55. It is common among Caucasians than
any other races. Familial history of breast cancer and ovarian cancer have higher chances
of acquiring the disease and increases if a family member was diagnosed before the age
of 50. Chances are, being diagnosed with breast cancer in one breast may increase the
likelihood of developing it in the other breast. Early menstruation before 12 and late
menopause after 55, nulliparity or late pregnancy may increase the risk of breast cancer.

3
 On the other hand, there are avoidable risk factors that may prevent its development.
It involves lifestyle, alcohol consumption, diet, radiation and hormonal therapy and
exposure to chemicals.

In this case study, we will be able to understand how breast cancer developed and
managed. The reason for choosing this case study is for increasing the knowledge and
understanding about its pathophysiology and being able to trace the patient’s current
status from her previous functionality. Exploring and learning more about the disease
process will contribute on the daily assessment and management of the patient and may
help other patients at risk for developing cancer from health promotion, disease
prevention, disease management and until death. The patient is a 57-year old female
diagnosed with breast cancer stage 4 and was admitted in the central intensive care unit
for further management of her disease.

II. Objectives:
General objective:
To apply the theories and best practices learned in adult health nursing in
planning, implementing and evaluating nursing intervention in patient with chronic
illness (breast cancer).
Specific Objectives:
At the end of the clinical immersion, the nurse will be able to:
1. Identify risk factors associated with breast cancer,
2. Understand the pathophysiologic process of breast cancer,
3. Correlate significant health history and findings with patient’s diagnostic results,
4. Integrate appropriate nursing and medical management based on patient’s
significant findings, and
5. Evaluate effectiveness of care rendered to the patient

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III. Nursing Health History

A. Demographic Data

Name: AAA
Sex: F
Age: 57 years old
Birthday: 09/01/1962
Birthplace: Batangas
Address: Paranaque City
Race: Filipino
Religion: Roman Catholic
Marital Status: Single
Admission Date: November 14, 2019- Department of Pay Patient Services
Education: Bachelor’s degree
Occupation: Presently unemployed, previously a merchandising officer
Blood type: O positive (11/19/19)

B. Chief Complaint: Difficulty of breathing

Admitting Medical Diagnosis:

Breast mass, Right

C. History of Present Illness:

Patient AAA is a 57-year old, roman catholic, Filipino, living in Paranaque City diagnosed
with breast cancer stage IV and known to be hypertensive and maintained on carvedilol
25mg/tab 1 tab once a day. She was active in her pre-hospital state until…

4 years prior to admission, patient felt a lump at her right breast described by relative
(sister) as a size of “kiat-kiat” (2x3cm). Since it is not associated with any symptoms, the

5
patient did not seek any medical consult nor taken any medications because the patient
was afraid of being diagnosed with breast cancer (patient has 3 sisters who was
diagnosed with breast cancer). The patient kept this information to herself until…

2 months prior to admission, patient started to experience episodes of shortness of breath

and difficulty of breathing associated with non-productive cough, back pain and fever but
unable to note the temperature. Her sister advised her to seek consultation and was
brought in St. Claire Hospital. She was admitted and diagnosed with community acquired
pneumonia, laboratory workups were done such as chest x-ray and complete blood count.
It has been found out that she had fluid in the lungs but unable to take note of the amount.
She was given unrecalled intravenous antibiotics completed for 7 days and was
discharged. A week after, recurrence of shortness of breath occurred, she was readmitted
and treated as hospital acquired pneumonia and given ceftazidime that was eventually
shifted to piperacillin tazobactam and shifted to moxifloxacin all with unrecalled doses,
frequency and until when it has been taken. Biopsy of right breast mass was also done
and revealed invasive lobular carcinoma. CT scan was also done but no results were
given. Due to non-resolution of shortness of breath, she was then referred to her sister’s
consultant in Philippine General Hospital.

1 month prior to admission, patient was brought to Philippine General Hospital and was
admitted at the department of pay patient services, 4 th floor. Blood work-up were done
such as complete blood count and electrolytes, CT scan with contrast was also facilitated.
Liver ultrasound was done with chest markings and noted that she had pleural effusion
and was advised to undergo chest-tube insertion. Consent for procedure was secured but
was also deferred thereafter due to resolving pleural effusion. She presented with
occasional cough, shortness of breath and constipation.

D. Past Medical History:

Patient has been healthy since childhood and had very active lifestyle. She completed
her immunization during childhood and has no known allergies to food and medication.
She has not been involved to any accidents and did not have any recent foreign travel.

6
 She has not vices; she is not as smoker nor an alcoholic drinker. Her caregiver denied
her use of illicit drugs as well. She as not diagnosed of any communicable disease such
as tuberculosis and non-communicable disease in the past such as hypertension,
diabetes, stroke and cardiovascular diseases until such time she was diagnosed with
breast cancer. She had her first menstruation during her teenage years as mentioned by
her sister but unable to give her gynecologic history. She has no children thus nulliparity
may be considered as a risk factor in her situation. She is already menopaused at the
age of 55 which may also contribute in developing breast cancer.

E. Family History

x x x x
DM

65-x 77-x

Emphysema
Complicated DM
Hypertension

42-x 63 42-x 59 8-x 55 51 49 46 44 42 39 35-x

CKD DM,HPN Amoebic Fever Breast Ca Uterine Breast Ca Ovarian Cyst Breast Ca
liver St.II polyp St.II (+) surgery (+)
chemotherapy
abscess (+) completed
(+) surgery (+) completed oophorectomy
chemotherapy (+) radiation
Dilation chemotherapy
therapy
and Brain mets
57 55 curettage

Breast Ca
St.IV
HPN
Hemorrhoids

Legends:
Male X Deceased

3
Female --- Boyfriend
9
3
Patient Diagnosed with breast cancer
y
9
o
y
o
7
 F. Gordon’s Functional Health Patterns:

Functional Before Hospitalization During Hospitalization

Health Pattern
Health She had no history of being sick during her She is currently managed as
Perception/ childhood days. She is not a smoker nor an breast cancer and had multiple co-
Health alcoholic and use of illegal drugs is unlikely. Her morbidities such as hypertension,
Management sisters stated that despite the fact they know that infection, fluid and electrolyte
breast cancer runs in the family, by the time she imbalance, nutritional status.
discovered that a lump was present in her breast,
she decided not to talk about it and did not even
seek consultation due to her anxiety of being
diagnosed with breast cancer just like her sisters.
Nutritional- According to her sister, she had been eating She has multiple electrolyte
Metabolic healthy foods and most of it are prepared at imbalance of hypokalemia and
home. However, she is also fond of eating from hyperkalemia and was being
fast food restaurants that serves foods high in managed with intravenous and
sodium content and may have contributed in her oral electrolyte replacement
developing hypertension. therapy. Weight has not been
assessed. She is currently having
milk feeding at 30 cc per hour via
infusion pump for nutritional
support.
Elimination Has not been assessed She has Foley catheter to urine
bag draining about 525-1700 ml of
clear, yellowish urine daily. Patient
has fluid balance ranging from 885
to 1855ml per day. Stool charting
was done and had presence of
hematochezia.

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Activity- The patient can do activities of daily living The patient was unconscious and
Exercise independently. She can provide self-care needs unable to perform activities.
such as eating, hygiene care and other physical Passive ranges of motion, passive
activities however, she is working at an office and mobilization and turning
due to a lot of paper works, it involves more on schedules have been facilitated as
sitting than being active. She does not actively a form of her exercise.
involve herself in exercises as verbalized by her
sister.
Cognitive- She finished her bachelor’s degree and possess Unable to assess since she is
Perceptual knowledge and skills in management. She had unconscious
good decision-making skills as mentioned by her
sisters but she had this fear of being diagnosed
with breast cancer and opted to keep her early
recognition of breast lump to herself.
Sleep-Rest She has no problems in sleeping at home but at Unable to assess quality of sleep
some nights, she needs to work-up late for and rest since she is unconscious
accomplishing requirements as a merchandising
officer.
Self- Unable to assess Unable to assess since she is
Perception/ unconscious
Self-Concept
Role- She had good relationship with her family and to Her sisters show some feelings of
Relationship her siblings. She has open communication with disappointments because since
them not until she found out the lump on her breast cancer runs in the family,
breast, she started being quiet about it. she should have acknowledged it
and seek consultation and
treatment. Two of her sisters were
diagnosed with breast cancer
stage 2 and undergone treatment,
both them already completed
cycles of chemotherapy that is

9
 why they regret her decision of
stating her condition in the late
process of the disease.
Sexuality- Unable to assess however, patient is nulliparity. Unable to assess since she is
Reproductive unconscious
Coping/ She is open about her problems and talks about Unable to assess since she is
Stress it with her sisters. She spends some time with her unconscious
Tolerance friends as a form of stress reliever and to cope up
with problems.
Value-Belief She is a roman catholic and goes to church every Unable to assess since she is
Sunday. She expressed by belief by praying. unconscious

IV. Review of Systems:

The patient appears to be pale with no rashes, redness nor abnormal pigmentation. It
may be due to the presence of low red blood cell count and may be a sign of anemia. It
was also associated with bleeding tendencies as manifested by presence of
hematochezia. Bruises were present as well due to daily blood extraction. Blood
transfusion may be recommended. There were no head injuries present however
headaches were unable to assess. There was no presence of glaucoma, cataracts and
jaundice. There were no ear discharges and nose bleeding and stuffiness. The patient is
not known to have any allergies and asthma, no presence of swelling and hives. The
patient has no presence of mouth bleeding but there are presence of lip and mucosal
ulceration probably due to decreased immune system and poor oral hygiene. It is
important to maintain good oral hygiene since it may cause development of infection.
There are no lumps, swollen glands, goiter and stiffness in the neck area.

Breast assessment were done during supine position. There is a present lump in
her right breast. She presents with asymmetrical breast in which her left breast is lower
than her right having inverted left nipple. There was no visible breast mass, necrosis and
wound. She was intubated via endotracheal tube connected to the mechanical ventilator

10
 and has whitish secretion. Suctioning secretions triggered the patient to gag but there
was no presence of coughing. Chest physiotherapy may be done to facilitate movements
of secretions from the chest area to the bronchus for ease of suctioning. The patient had
no murmurs and abnormal heart sounds; however, she is known to be hypertensive and
is on cardiac medication. Cardiac monitor was attached to her chest for continuous
monitoring of her heart rhythm. Her gastrointestinal status shows presence of bleeding,
she has yellowish output from her nasogastric tube and presence of hematochezia
estimating 150 ml of blood in her diaper but she has no abdominal distention. She also
has hemorrhoids. Her urinary status was poor since urinary retention may be considered
leading to fluid volume excess in her body. She has an indwelling Foley catheter to urine
bag draining yellowish clear urine. She does not have any visible varicose veins and
thrombophlebitis. She is paraplegic and shows weakness on both upper and lower
extremities. Her neurologic status was also poor since she is unresponsive, intubated and
responds to pain given a Glasgow Coma Scale of E2VTM4 with positive paralysis and
weakness. There is no occurrence of seizures and involuntary movements. Her endocrine
status on the other hand is normal as of the moment.

V. Physical Examination:
VITAL SIGNS:

Date Heart Rate Blood Respiratory Temperature Oxygen MAP

(bpm) Pressure Rate (cpm) (*C) Saturation (mmHg)
Dec.1 56-63 110/60-120/70 12-32 36.1-38.2 99-100% 76.66-86.66
Dec.2 33-63 110/60-130/65 14-18 37.4-38.0 99-100% 76.66-86.66
Dec.3 57-72 130/60-160/75 12-26 36.1-37.8 99-100% 83.33-
103.33
Dec.4 65-100 123/60-159/60 12-20 36.4-37.2 99-100% 81-93
Dec.5 68-85 146/76-165/90 16-26 36.0-38.4 99-100% 99.33-115

11
 Patients vital signs were monitored hourly using cardiac monitor. Daily vital signs
show the least up to the maximum values during each given day. The patient had
episodes of bradycardia that is why there is a standby Atropine Sulfate 0.5mg IV as
needed if in case it happens again. Sinus bradycardia may occur to the patient due to
rest and sleep state however, there are parameters to determine whether or not she is to
be classified as unstable. One parameter is hypotension, she maintained her blood
pressure above 90/60 which does not require her to use Atropine Sulfate. Other
parameters such as signs of congestive heart failure, acute coronary syndrome, decrease
level of conscious and signs of difficulty of breathing may possible appear so close
monitoring of her heart rate must be observed. She had febrile episodes and may indicate
presence of infection. It may also be supported by her increasing heart rate trends from
bradycardia to normal sinus rhythm and may go up as necessary. Respiratory rate and
oxygen saturation were controlled and manipulated by mechanical ventilation to maintain
normal parameters. Mean arterial pressures were maintained at a normal level of 60-
100mmHg, however, elevated MAP of 115mmHg seen at Dec. 5 may mean that there is
an increase pressure in her arteries that may lead to clot formation or damage to heat
muscles since it has to work a lot harder.

CBG trends 4am 8am 12noon 4pm 8pm 12mn

Dec 1 149 149
Dec 2 154 139 141 160 146 164
Dec 3 130 143 167 174 152 178
Dec 4 186 150 141 124 146 126
Dec 5 138 105 128 142 138 148

Capillary blood glucose test must be assessed even though the patient is not know
diabetic. It is because the patient has been maintained on nil per os to drain gastric
content and to prevent gastric inflation probably due to advanced airway management.
Patients’ blood glucose level may drop from the normal value that is why the patient is
maintained on a dextrose containing intravenous fluid such as balanced multiple
replacement with 5% dextrose. The normal capillary blood glucose level in a normal

12
individual is 80-120mg/dl, however it may drop due to decrease oral food intake or may
be increased. Rescue doses of fast acting insulin in case her glucose level increased to
180mg/dl.

Pain Scale: Unable to assess pain level, but present when eliciting pain for
neurological assessment.

ANTHROPOMETRIC MEASUREMENTS:
Height: unable to assess
Weight: unable to assess
Body Mass Index: unable to assess

GENERAL SURVEY:
The patient is unconscious and unable to assess coherence and orientation. She
does not presently exhibit signs of cardiorespiratory distress and tolerates current
mechanical ventilation settings. She is endomorph and generally has a pale and moist
skin. She presents with good hygiene and has no foul body smell, well-combed hair and
partially trimmed nails.

NEUROLOGIC STATUS:
The patient is unconscious and unresponsive with Glasgow Coma Scale of
E2VTM4 wherein her eyes open to pain, has an advanced airway and withdraws from
pain. Cranial nerves are assessed however, some findings were not gathered such as
cranial nerves I-for olfactory, III, IV, VI-for extraocular movements, V- for facial muscles,
VII- for taste sensation, VIII- for gross hearing on both ears, IX,X,XI for gag reflex and
shoulder shrug, . Cranial nerve II shows bilateral 2cm pupil size and has equally round
and reactive to light and accommodation. It is important in determining presence of
neurologic disease. She had no signs of ptosis but exhibits lid lag most commonly
associated with thyroid disease but she was not diagnosed with any thyroid problem.
Cranial nerve VII does not show any facial asymmetry. Cranial nerve XII shows that her
tongue is in midline. The patient had sensory assessment on both upper and lower

13
extremities is 100% and in motor of 1/5 in both upper and lower extremities. According to
the International Standards for Neurologic Classification of Spinal Cord Injury, 1/5 means
that there is some muscle activity (palpable or visible), but unable to move against gravity.
Patient has supple neck and there is absence of Brudzinski and Kernig ruling out
meningitis.

SKIN:
The patient is pale in color and may be associated with low red blood cell count.
Jaundice is absent which means that there is no liver problem and cyanosis is absent
meaning there is adequate oxygenation in the system. Patient is cold to touch maybe
affected by environmental factors. She has good skin turgor and capillary refill of <2
seconds.

HEAD AND FACE:

Patient presents with normocephalic and symmetrical head with no palpable mass,
lesions nor scars. The scalp is clean, hair is coarse and fine with normal distribution
therefore no alopecia is present. There is absence of bruit on temporal artery and absence
of tenderness.

EYES:
Patient has no nystagmus but Doll’s eye also called oculocephalic reflex and gaze
is present. It is important to test for brain function in comatose patients. A positive Doll’s
eye reflex means that there is no brainstem dysfunction. Cranial nerve II shows bilateral
2cm pupil size and has equally round and reactive to light and accommodation. Cranial
Nerve III, IV, VI shows no ptosis and presence of lid lag. She has pale palpebral and
bulbar conjunctiva. Her eyebrows are symmetrically aligned and hair evenly distributed
and skin intact. Eyelashes were equally distributed and curled slightly outwards. Eyelids
are symmetrical and in level with each other. There were no discharges, swelling, lesions
nor tearing of lacrimal duct upon palpation.

14
EARS:
The patient has no foul-smelling ear discharge but with minimal moist cerumen.
She has normoset and bilaterally symmetrical ears and is proportionate with the head
and face that has same color with the face. There were no visible lumps nor lesions.
Tenderness, pain and gross hearing cannot be assessed.

NOSE:
The patient has symmetrical nasolabial fold with no deformities, lesions and
deviations. The septum is in midline with pinkish mucosa. There were no present masses,
polyps nor discharges. There was no presence of nasal flaring though tenderness were
not assessed. She has siliconized nasogastric tube level 65 at left nares, open to drain to
bedside bottle, draining yellowish output around 100ml but progressed to milk drip feeding
to nasogastric tube after 2 days. Feeding of Peptamen 4 scoops in 150 ml water to be
infused as drip feeding for 30cc/hour every 6 hours was ordered.

MOUTH:
The patient has oropharyngeal airway (green) and has pale symmetric dry lips.
Cranial nerve XII shows that her tongue is in midline with no present atrophy,
fasciculations nor lesions. Her buccal mucosa is slightly pale, but moist with minimal
ulcerations. Slurring and speech quality were not assessed.

PHARYNX:
Unable to visualize patients’ uvula, tonsils and palate.

NECK:
The patient has supple neck but there was no enlargement of thyroid gland and no
neck vein engorgement. There were no visible masses and lesions. Trachea is in midline
and there was non-tender, non-palpable lymph nodes. No visible masses, neck
enlargement and lesions. Carotid artery had symmetrical rate and rhythm. Cranial nerve
XI demonstrates weakness.

15
CHEST AND LUNGS:
The patient was intubated with endotracheal tube size 7.5 level 19 to mechanical
ventilator. Settings are indicated below. There are minimal thick yellowish secretions per
endotracheal tube. She has a respiratory rate of 18-24 cycles per minute with regular
rhythm controlled by the ventilator. An apicolordotic ratio of 1:2 presents her chest
characteristics with equal chest expansion with an inspiration/expiration ratio of 1:1 as
controlled by the mechanical ventilator. She also has bilateral upper lung lobe crackles
with bilateral rhonchi that is more prominent on the right side. This may indicate that the
patient may be at risk for pulmonary congestions due to fluid shifting. There are no visible
intercostal space retraction and bulging.

Mechanical ventilation settings Dec 2 Dec 3 Dec 4 Dec 5 Dec 6

Mode AC-VC SIMV SIMV AC-VC AC-PC
FiO2 60% 40% 40% 40% 40%
Tidal volume 400 360 340 360
Back up rate 18 12 15
PEEP 8 8 5 5 5
IFR 70
Sensitivity 2 1.5 1 1 1
Pressure support 14 16
Pi 20
Ti 0.80

The patients’ mechanical ventilation was primarily assist-control mode-volume

controlled. It means that the patient always receives at least the set tidal volume. Every
detected inspiration effort of the patient at PEEP level triggers an additional mandatory
breath. The patient thus determines the number of additional mandatory breaths.
Continuous assist-control mode may have the risk of developing hyperinflation or
alkalosis so it is important to assess and wean the patients’ settings down once tolerated.
Since the patient was able to tolerate the current settings, she was weaned down to
synchronized intermittent mandatory ventilation in which the patient is allowed to take

16
additional breaths in between the mechanical breaths. The patient’s own breaths are
called spontaneous breaths. Disadvantages of SIMV are increased work of breathing and
a tendency to reduce cardiac output, which may prolong ventilator dependency. The
addition of pressure support on top of spontaneous breaths can reduce some of the work
of breathing. On the other hand, the presence of positive end expiratory pressure
displaces the entire pressure waveform thus mean intrathoracic pressure increases and
the effects on cardiac output are amplified. Low levels of PEEP can be very dangerous
even with 5 cm H20, especially in patients with hypovolemia or cardiac dysfunction (Crit.
The patient was placed back at assist-control mode volume-controlled and was switched
to pressure-controlled wherein there is less risk of barotrauma because it does not allow
patient-initiated breaths. The inspiratory flow pattern decreases exponentially, reducing
peak pressures and improving gas exchange (Chest, 2002).

HEART:
The patient is attached to a 5-lead cardiac monitor to facilitate continuous
monitoring of heart electrophysiology. The patient initially presented with sinus
bradycardia ranging from 56-59 beats per minute having 33 bpm as the lowest that is why
standby intravenous Atropine Sulfate 0.5mg every 15 minutes is readily available for heart
rate <40 and <50 if hypotensive. However, according to the American Heart Association
(2015) and other references cited, intravenous Atropine Sulfate 0.5mg may be given
every 3-5 minutes maximum of 3 mg in 6 doses provided that the patient is symptomatic.
The heart rate is distinct, regular that can be heart in the 5 th intercoastal space, left
midclavicular line where the point of maximum impulse can be heard. No murmurs,
heaves and thrills present. She has distinct heart sound with s1 louder than s2 at apex
and s2 louder than s1 at the base. No extra heart sounds such as s3 and s4 present.

BREAST AND AXILLAE:

The patient has is a present lump in her right breast. She presents with
asymmetrical breast in which her left breast is lower than her right having inverted left
nipple. There was no visible breast mass, necrosis, wound and breast atrophy. Axillary
lymphadenopathy was not assessed at this time.

17
ABDOMEN:
The patient has a soft, round abdomen with no visible enlargement of spleen and
liver. No pulsations and protrusions present on the umbilicus. Normoactive bowel sounds
of 12 per minute upon auscultation means that there no presence of intestinal paralysis.
It is tympanitic upon percussion. Tenderness and guarding behavior were unable to
assess. No bladder distention and fluid wave and shifting dullness noted.

GENITO-URINARY:
The patient has no vaginal discharges, nodules, growth nor lesions. She has Foley
catheter french 16 to urine bag draining clear yellowish urine output. Urinary output as
indicated below.

Date Dec 1 Dec 2 Dec 3 Dec 4 Dec 5

Intake 1410 3565 3180 3369 3555
Output 525 815 800 1380 1700
Fluid balance 885 2750 2380 1909 1855

It is important to take note of the fluid balance to determine whether or not fluid
retention occurs within the patient. It is reflected that her intake is greater than her output
and may be associated with the fluids she is having such as intravenous fluids, milk
feeding per nasogastric tube. It may also be correlated with her sodium levels which is
elevated that may further attract water.

RECTAL:
The patient had undergone digital rectal exam done by the resident on duty and
presented with bright red clots with no palpable mass on internal examination. This may
indicate lower gastrointestinal bleeding and may be associated with her having
hemorrhoids. During December 4, there was presence of maroon colored bowel
movement, soaking ½ of the diaper and was referred to gastrointestinal service and
hemoglobin and hematocrit was closely monitored. The day after, her stool was noted to
be brown in color.

18
BACK AND EXTREMITIES:
The patient had an intravenous cannula gauge 22 (blue) at right metacarpal vein to
heparin lock. It was eventually shifted and connected to fluids such as dextrose 5% in 0.9
sodium chloride 1 liter + 40 meqs potassium chloride x 8 hours x 2 cycles were attached
to the right. There is a side drip of plain lactated ringers 100 ml + 20 meqs potassium
chloride x 2 cycles. Fluids were changed to 0.9 sodium chloride 1 liter x keep vein open
after the potassium drip, however, due to hypernatremia, it was shifted to lactated ringers
solution 1 liter x keep vein open. Since the patients’ serum potassium were still low, side
drip of 0.9 sodium chloride 90 ml + 20 meqs potassium chloride x 3 hours x 4 cycles was
restarted.

On the left side, there was an intravenous cannula gauge 22 (blue) at left brachial vein
to dextrose 5% in 0.9 sodium chloride 1 liter to run for 10 hours. Since the patient has no
food intake, her fluids were shifted to balanced multiple replacement with 5% dextrose 1
liter x 25cc per hour.

Due to presence of several intravenous fluids that may contributed to her fluid
retention associated with electrolyte imbalance and immobility, non-pitting bilateral upper
extremity edema was seen on her metacarpals. She has pale nailbeds. Grade II pressure
injury was seen in her sacral area. She has motor score of 1/5 on both upper and lower
extremities. She also has strong, equal radial, popliteal, dorsalis pedis pulses with good
capillary refill of <2 seconds.

Braden Scale Skin Assessment

Sensory Perception 3
Moisture 2
Activity 1
Mobility 2
Nutrition 2
Friction and shear 2

19
 VI. Diagnostics and Laboratory Results:

Blood Chemistry Normal levels 11/15 11/17 11/18 11/27 11/29 12/2 12/2
Potassium 3.5-5.1 mmol/L 3.3 2.2 2.2
Sodium 137-145 mmol/L 142 150 151
Calcium 2.10-2.55 mmol/L 3.40 3.00 2.74 2.45
Albumin 35-50 g/L 32 30 29 22
Blood Urea Nitrogen 2.5-6.1 mmol/L 10.6
Creatinine 46-92 umol/L 95 73 129
Phosphorus 0.81-1.49 mmol/L 0.6
Magnesium 0.70-1 mmol/L 0.87
eGFR >60/min 57.77 78.53
AST 15-41 IU/L 46
ALT 17-63 IU/L 25
Alkaline 38-126 IU/L 382
phosphatase
Procalcitonin <0.25 ng/ml 2.68

Blood Chemistry Normal levels 12/3 12/4 12/4 12/5 12/5 12/6
Potassium 3.6-5.1 mmol/L 2.8 2.8 3.2 3.5 3.6 3.3
Sodium 136-144 mmol/L 153 154 154 155 155 153
Calcium 2.10-2.55 2.38 2.19 2.30
mmol/L
Albumin 35-50g/L 23 22 24
Phosphorus 0.81-1.49 mmol/L 0.61
Magnesium 0.70-1 mmol/L 0.95
BUN 2.5-6.1 mmol/L 11.8
Creatinine 46-92 umol/L 111

20
The patient presents with multiple electrolyte imbalance such as hypokalemia,
hypernatremia and hypercalcemia associated with elevated blood urea nitrogen and
creatinine level which determines kidney function. Sodium and potassium are inversely
proportionate with each other wherein when sodium goes up, potassium goes down.
Hypernatremia is a higher than normal serum sodium level. It may be associated with
different causes such as gain of sodium in excess of water or by a loss of water in excess
of sodium. It can occur in patients with normal fluid volume or in those with fluid volume
excess or deficit. With a water loss, the patient loses more water than sodium resulting in
concentrated serum sodium and the increased concentration pulls fluid out of the cell. In
sodium excess, the patient ingests or retains more sodium in the water in which water
were pulled out from the cells from extra cellular fluid. Increased serum sodium will attract
more water from the cells to the circulation. Fluid deprivation is common especially with
unconscious patients who cannot perceive, respond or communicate (Madias, 2000 as
cited by Brunner and Suddarths’). Urine specific gravity and urine osmolality are
increased as the kidneys attempt to conserve water. Hypernatremia consists of a gradual
lowering of the serum sodium level by infusion of hypotonic electrolyte solution. Since
patient is receiving 0.9 sodium chloride, it has been shifted to plain lactated ringers’
solution which gives 300mg less than the previous fluid. Diuretics may also be given to
decrease serum sodium gain. Assessment for abnormal losses of water or low water
intake for large gains of sodium is important. Fluid intake is inadequate that is why fluid
flushing of 250 cc were ordered to ensure adequate enteral fluid intake. The higher the
osmolality of the enteral feeding, the greater the need for water supplementation. It is the
responsibility of the nurse to review serial serum sodium levels and observe for neurologic
changes.

Since potassium is inversely proportionate with sodium, hypokalemia occurred.

However, since potassium is the major intracellular electrolyte, only 2% remains in the
extracellular fluid in which is important in neuromuscular function. It influences both
skeletal and cardiac muscle activity. Hypokalemia usually indicates an actual deficit in
total potassium stores. When alkalosis is present, temporary shift of serum potassium
into the cells occur. Common cause of hypokalemia is gastrointestinal loss of potassium

21
in which the patient has nasogastric tube draining gastric secretions into the bottle.
Potassium may also be lost through the kidneys in association with metabolic alkalosis.
Arterial blood gas values is important for assessment of acid-base balance. The
mechanism involves shifting of hydrogen and potassium ions between the cells and the
extracellular fluids. The patient has capillary blood glucose monitoring and sliding scale
of insulin doses were administered as needed. Insulin may also promote the entry of
potassium into skeletal muscle and hepatic cells therefore lowering the serum potassium.
It is also important to take note of the magnesium level since depletion of it causes renal
potassium loss and must be corrected first; otherwise, urine loss of potassium will
continue. Severe hypokalemia may cause cardiac or respiratory arrest that is why it is
important that the patient receives potassium supplement either via intravenous route or
oral or per nasogastric tube to increase potassium levels. If this condition is prolonged, it
can lead to an inability of the kidneys to concentrate urine causing it to be diluted.
Constant monitoring of serum potassium and electrocardiogram is important. Determining
presence of T wave and/or inverted T waves suggesting ischemia, and depressed ST
segments. An elevated u wave is specific to hypokalemia. Being able to assess bowel
motility is also important to determine muscle activity in the gastrointestinal tract.

Hypercalcemia is also a dangerous imbalance when severe. Since the patient is

immobile and unable to do activities, bone mineral is lost causing elevation of total and
ionized calcium in the blood stream. It also contributes to patient having disturbed renal
tubular function which causes excessive urination thus diluted urine occurs. Serum
calcium level must also be assessed regularly and electrocardiogram must be observed
for shortening of the QT interval and ST segment. In relation to patients disease process,
her cancer was already metastasized to several bones which causes bone
demineralization and release of calcium in the blood. Administration of fluids to dilute
serum calcium is indicated. 0.9% sodium chloride solution temporarily dilutes serum
calcium and increases urinary calcium excretion by inhibiting tubular reabsorption of
calcium. Furosemide may be given as well to facilitate urinary excretion of calcium and
may also help in preventing development of pulmonary congestion related to fluid

22
administration. Calcitonin may also be recommended to lower serum calcium level and is
particularly useful for patients with heart disease or renal failure.

Hypoalbuminemia is also an indicator of malnutrition in patients. It may also occur

due to overhydration, liver or renal disease and excessive protein loss because of cancer
(Dudek, 2000 as cited by Brunner and Suddarths’). When computing for calcium levels,
albumin is also considered. When arterial pH increases, more calcium becomes bound
to protein, as a result, ionized portion decreases.

Blood urea nitrogen and creatinine determines kidney function. Elevated levels
suggest renal impairment in which the patient exhibits problem in electrolyte balance and
may decrease blood flow to the kidneys. It may also be used to assess glomerular filtration
wherein high levels indicate inability to excrete nitrogenous waste products. Initially the
patients’ glomerular filtration rate is below 60 however, it went back up and may indicate
that the present management is working.

AST and ALT were assessed to determine liver function, since both are within
acceptable levels, there is no active liver damage. It is important to be assessed since
the patient had breast cancer stage IV, metastasis is most likely to occur. It is also
important to identify presence of deterioration of hepatic function because it may increase
the risk of other systemic side effects because drug metabolism is influenced by liver
dysfunction.

Procalcitonin is a substance produced by many types of cells in the body, often in

response to bacterial infection but also in response to tissue injury. The level of
procalcitonin in the blood has increased significantly due to systemic bacterial infection
and sepsis.

23
 CBC Normal levels 11/17 11/20 11/27 11/29 12/2 12/3 12/3 12/4
WBC 4.5-11.0x 10^9/L 7.70 9.40 8.30 10.70 10.50 9.70 8.80
RBC 4.2-5.4x10^9/L 2.98 4.57 3.67 3.36 2.74 2.46 3.50
Hgb 120-160 g/L 87 138 109 101 84 75 104 68
Hct 0.38-0.47 0.27 0.42 0.34 0.31 0.25 0.23 0.31 0.21
MCV 80-96 fL 90 92.1 91.4 93.4 91.3 91.5 89.8
MCH 27-31 pg 29.1 30.1 29.8 30.0 30.6 30.5 29.7
MCHC 320-360 g/L 323 327 326 321 335 333 331
RDW 11.0-16.0 16.4 14.9 15.0 14.9 15.4 15.8 15.3
PC 150-450x10^9/L 307 303 173 153 114 127 102
Neutrophil 0.50-0.70 0.67 0.82 0.71 0.76 0.75 0.64 0.67
Lymphocyte 0.20-0.50 0.20 0.10 0.17 0.16 0.20 0.27 0.27
Monocyte 0.02-0.09 0.11 0.06 0.09 0.08 0.04 0.05 0.04
Eosinophil 0-0.06 0.02 0.02 0.02 0.00 0.01 0.04 0.02
Basophil 0-0.02 0.00 0.00 0.01 0.00 0.00 0.00 0.00
Absolute >1,500 5,159 7,708 5,893 8,132 7,875 6,208 5,896
neutrophil count

Determining patients’ complete blood count will provide baseline data regarding
her status for developing infection, anemia and risk for bleeding. The patients white blood
cell count is within normal range in relation to her absolute neutrophil count, all of which
are greater than 1,500 therefore there is likely to have no infection at the moment.
Differential counts are within normal levels as well except neutrophils and lymphocytes
wherein neutrophils are essential in preventing and limiting bacterial infection and
lymphocytes helps in patrolling the tissues and vessels that drain the areas served by
lymph nodes. It means that lymphocytes are doing its surveillance to prevent an incoming
infection. Low levels may have decreased defenses from viral infections. It may also be
associated with renal injury. Administration of broad-spectrum antibiotics by means of
Piperacillin-Tazobactam were given to fight current and developing infection especially
ventilator-associated pneumonia. There is a slight increase in monocytes signifying that

24
there are active phagocytic cells that remove foreign materials or microorganism from site
of injury (tumor). Eosinophil and basophil indicates absence of allergic reaction.

Moreover, red blood cells carry oxygen throughout the body. Having low levels of
red blood cells may indicate anemia and may also decrease oxygen carrying capacity.
Patient had episodes of bleeding tendencies in a form of hematochezia, so it is important
to ensure that risk for bleeding must be monitored. Furthermore, since there are few red
blood cells, hemoglobin – an oxygen-carrying molecule is made up of 4 subunits, each
containing a heme portion attached to a globin chain. The ability of the heme is to bind to
oxygen loosely and reversibly. It is bound in the red cells and is responsible for
transporting oxygen and carbon dioxide from the blood stream to the cells and vice-versa,
low levels of hemoglobin may be an indication of anemia and oxygenation delivered to
tissues are inadequate. It may be the reason the patient is pale in color and cold to touch.
Therefore, blood transfusion of two units of packed red blood cells were done to increase
red cells and hemoglobin levels. Hematocrit is the percentage of blood that is made up of
red blood cells. Decreasing trends of hematocrit means that there is also anemia and, in
relation to the patient’s condition, overhydration may also be the cause.

Other values such as MCV, MCH, MCHC, RDW are within normal range meaning
the there is a normal volume of red blood cells, normal amount of hemoglobin in an
average cell, normal average concentration of hemoglobin per erythrocyte and uniform
individual cell size respectively. At first, platelet concentrate are within normal limits
however it decreased in the latter part and may put the patient at risk for bleeding
tendencies manifested by hematochezia.

25
 ABG Normal levels 11/29 11/30 12/2 12/3 12/4
T 37 37 37 37 37
Hb 14.9 13.4 9.1 7.6 7.6
FiO2 60 35 60 40 40
pH 7.35-7.45 7.484 7.672 7.728 7.496 7.46
pCO2 35-45 mmHg 63.2 30.8 25.7 46.8 46.8
pO2 90-100 mmHg 172.1 41.8 79.4 93 93.0
HCO3 22-28 meq/ L 48 36 34.3 36.5 36.5
BE -2.4- -2.3mmol? 20.9 15.7 14.9 12.8 12.8
O2sat >94% 99.6 89.5 98.6 97.6 97.6
TCO2 24-28mmoL/L 49.9 37 35 37.9 37.9
SBc 45.8 39.5 38.8 36.5 36.5

The above findings indicate partially compensated metabolic alkalosis with severe
hypoxemia with increased pH, increased PaCO2 and increased HCO3. On the other
hand, increased pH, decreased PaCO2 and increased HCO3 may be interpreted as
mixed alkalosis.

Metabolic alkalosis may be caused by severe or prolonged vomiting, in the

patient’s case, her gastric contents are drained from nasogastric tube leading to
electrolyte imbalance. Other causes such as inadequate excretion of acids due to renal
disease, loss of potassium due to increased renal excretion may present metabolic
alkalosis. Signs and symptoms associated to it are slow, shallow breathing, confusion,
hypertonic muscles, twitching, restlessness, apathy, irritability, tetany, coma and
seizures.
High base excess indicates that there is a higher than normal amount of HCO3 in
the blood, which may be due to a primary metabolic alkalosis or a compensated
respiratory acidosis. Total carbon dioxide is a measure of carbon dioxide which exists in
several states; carbon dioxide in physical solution or loosely bound to proteins,
bicarbonate or CO3 ions, and carbonic acid. Bicarbonate ions make up all but

26
approximately 2 mmol/L of the total carbon dioxide of plasma. Measurement of TCO2 as
part of an electrolyte profile is useful to evaluate bicarbonate concentration.

Urinalysis Normal levels 12/2

Color Dark yellow
Transparency Slightly cloudy
Bilirubin <17 umol/L Negative
Urobilirubin <35 umol/L Normal
Ketone <1.5 mmol/L Trace
Glucose <2.8 mmol/L Normal
Albumin <0.3 g/L +1 (0.3 g/L)
Blood <5 erys/uL +3 (300 Ery/uL)
pH Acidic 5.0 (Acidic)
Nitrite Negative Negative
Leucocytes <25 leukos/uL +2 (75 Leu/uL)
Specific Gravity 1.010 1.037
RBC 0-9/uL 1223 H
WBC 0-22/uL 136 H
Epithelial Cells 0-13/uL 0
Bacteria 0-220/uL 453
Mucus Thread 0-13/uL 31

Urinalysis was done to determine presence of urinary tract infection and kidney
function. It shows dark yellow meaning it is concentrated commonly due to dehydration.
However, since the patient’s serum sodium levels are high, it may be the opposite in
which the there is a presence of overhydration but unable to excrete urine properly.
Cloudy urine may occur occasionally due to mild dehydration and is supported by
elevated specific gravity.
Presence of protein may also contribute in its transparency. High count of red blood cells,
white blood cells, and bacteria may indicate infection.

27
 PT/PTT Ref value 11/27 12/2 12/3 12/4
PT ref sec 12.6 12.6 12.6 12.6
PT time 11.4-13.9s 14.3 20.7 17.4 15.8 H
PT% % 83 51 63 72
PTINR 1.14 1.66 1.39 1.26
APTT ref 30.38 30.38 30.38
APTT time 35.8-35 sec 34.7 39.4 35.7

Coagulation test such as prothrombin time is used to monitor patients for clotting
disorders. It specifically evaluates the presence of factors VII, V and X, prothrombin and
fibrinogen. Prothrombin time within normal range indicates that the patient has normal
clotting factors, however, prolonged prothrombin time indicates deficiency in any factors
VII, X, V, prothrombin or fibrinogen. It may mean that the patient has vitamin K deficiency
since it is a co-factor in the synthesis of functional factors II, VI, IX and X, or a liver
disease. The patient receives intravenous vitamin K to facilitate deficiency. Furthermore,
activated partial thromboplastin time test is performed to investigate bleeding disorders
and to monitor patients taking an anticlotting drug such as heparin, (in patients’ case,
enoxaparin), which inhibits factors X and thrombin, while activating anti-thrombin.
Increased levels with bleeding disorder indicate a clotting factor may be missing or
defective. At this point further, investigation is needed and warrants the use of sensitive
assays for specific coagulation factors.

Electrocardiogram:
Rate: 55 bpm T: Present, upright
Rhythm: Regular ST: Isoelectric line, no
P: Present (Sinus) ST elevation
QRS complex: Narrow, <20sec P:QRS ratio: 1:1

Interpretation: Sinus bradycardia with heart rate of 55 beats per minute, ST-segment on
isoelectric line with upright T-wave.

28
 Monitoring patient’s electrocardiogram continuously via 12-lead ECG or cardiac
monitor is vital to determine cardiac function. Sinus bradycardia is normal in patients at
rest and athletes; however, the patient is in a state of unconsciousness further putting the
patient at rest. There are no significant electrophysiologic problems at the moment but it
is important to determine patients’ bradycardic state whether or not she is symptomatic/
unstable or stable. To do so, since the patient has altered level of consciousness, it is
already considered as one of the parameters to determine stability. Aside from it,
hypotension of BP <90/60, presence of signs and symptoms of acute coronary syndrome,
heart failure and respiratory distress may also be an indicator. Intravenous atropine
sulfate 0.5mg must be readily available to increase patients heart rate. Intravenous
dopamine 2-20mcg/kg/min and epinephrine 2-10mcg/min may also be given as drip.

Endotracheal Aspirate Gram Staining

12/5
PMN >10/LPF
SQ. Epith Cells: <10/ LPF
Gram (-) Diplococci: None/ OIF
Yeast Cells: None/ OIF
Hyphal elements: None/OIF
Gram (+) cocci n pairs: None/ OIF
Gram (+) in chain: None/ OIF
Gram (-) Bacilli: None/ OIF
Gram (+) Bacillia: None/ OIF

12/2 Urine CS- No growth 2 days of incubation

12/2 Blood CS- No growth 2 days of incubation

In the patients ETA GS, PMN known as polymorphonuclear leukocytes are a

special family of white blood cells. It is a type of immune cell that has granules with
enzymes that are released during infections. In line with this, presence of epithelial cells
is also indicative of an infection. Ventilator assisted pneumonia bundles of care must be

29
practiced at all times to prevent occurrence of an infection in the respiratory system. On
the other hand, there are no evidences of bacterial growth in the urine and blood.

Liver Ultrasound
11/18/2019
Normal Liver Ultrasound
The liver is normal in size with homogenous parenchymal echo pattern. It has
smooth borders and no focal lesions were seen. The common bile duct (2.1mm) and
intrahepatic ducts are not dilated. The portal vein and intrahepatic veins, as well as the
inferior vena cava are unremarkable. Thus, yielding a result of normal liver ultrasound
and has not metastasize in this organ. It may confirm the diagnostic value of AST, ALT
for further confirmation of liver function.

With chest markings:

The chest scan was taken while the patient is in a seating position via posterior
and lateral approach. It shows pleural fluid collection in the right hemithorax with an
approximate volume of 350 ml. Extensive internal septations are observed. There is
atelectasis of the adjacent lung segments and the left lung is well aerated. Patient
presented with complicated pleural effusion at right side.

During this time, pleural fluid was seen on the patients right hemithorax, it means
that the breast cancer spread in which extra fluid can build up inside the pleura and be
diagnosed with pleural effusion. It was considered that the patient should undergo chest
tube insertion however, the lung fluid eventually decreased. Continuous monitoring of
lung and breath sounds is important to determine reoccurrence of the condition. Accurate
fluid administration must be observed and output must be recorded to determine fluid
balance.

30
Bone Scintigraphy 12/3/19
Ectopic right kidney was located more anteriorly in the right lower abdomen while
left kidney appeared unremarkable.
Foci of abnormal traces accumulation consistent with bone metastasis where
seen:
• Skull (multiple sites) • Multiple bilateral ribs
• Both scapulae • Multiple vertebrae
• Left sternoclavicular joint • Bilateral pelvic bones
• Sternum

Impressions:
1. Hypodensity in the midbrain, may present an infarct of indeterminate age versus
artifact.
2. Multiple calvarial, skull base, and cervical spine lucencies, likely metastasis if
proven to have a primary malignancy
3. Mild cerebral volume loss
4. Polysinusitis
5. Consider mastoiditis, bilateral

Bone scan is indicated to determine bone metastasis. It shows that the patient
presents with multiple bone metastasis causing osteolysis allowing the release of
calcium in the blood, hence elevated calcium is seen in the patient. Pain medications
may be given to the patient round the clock since bone metastasis can be very painful
to the patient.

Immunohistochemistry
Estrogen receptor assay
Strong intensity - strong labeling
% tumor cells stained -80%
Progesterone receptor assay
Staining intensity -strong labeling

31
%tumor cells stained -40%
Result: (+) for both estrogen receptor and progesterone receptor
(-) HER2/ neu overexpression

A cancer may be called estrogen-receptor positive if it has receptors for estrogen. This
suggests that the cancer cells, like normal breast cells, may receive signals from estrogen
that could promote their growth. On the other hand, progesterone-receptor positive occurs
if it has progesterone receptors. This means that the cancer cells may receive signals
from progesterone that could promote their growth. Since the cancer cells have positive
hormone receptors for both estrogen and progesterone, medications such as hormonal
therapy may slow or even stop their growth. It is the reason why the patient is taking
Tamoxifen as a selective estrogen receptor modulator which is the most prescribed
hormonal drug.

VII. Pathophysiology:
Patient is a 57-year old female patient and is already on her menopausal stage. She
did not have any children which place her at risk since nulliparity is also one of the risk
factors of breast cancer. Risk of having breast cancer may be decreased due to early
pregnancy and longer breastfeeding time, thus, it is most likely that the patient was
diagnosed due to nulliparity. She is obese as visually assessed however, weight and
height were not able to measure due to patients’ unconscious state, physical inactivity in
which her responsibilities in the office mostly involves sitting. Chest x-rays and CT scans
may also contribute as a risk factor in developing breast cancer.

According to Brunner and Suddarths’, 5% to 10% of all breast cancers are hereditary
with genetic mutations cause up to 80% of breast cancers in women younger than 50
years old. It has also been linked to specific mutations in tumor suppressor genes, such
as BRCA-1 and BRCA-2 and TP54, which normally slows down cell division or make cells
die if the divide uncontrollably. Two breast cancer susceptibility genes BRCA1 on
chromosome 17 and BRCA2 on chromosome 13 may account for most inherited forms
of breast cancer. BRCA1 is known to be involved in tumor suppression, on the other hand,

32
BRCA 2 is another susceptibility gene that carries an elevated cancer risk similar with
BRCA1. Mutations in BRCA-1 or BRCA-2 are both autosomal dominant, which can be
inherited and cause familial breast cancer which also cause an increased risk of ovarian
cancer. Genetics highly contributes her being diagnosed with breast cancer since she is
already the fourth among the family to have the disease, one of which died and two had
completed their chemotherapy. ERBB2 gene receptors increase human epidermal growth
factor receptor 2( HER-2), which when activated, promotes the growth of cells. Each time
cells divide there’s a chance that a genetic mutation will occur and a mutation, can lead
to tumor formation.

Cells of glandular tissue have receptors for estrogen and progesterone which are
released by the ovaries, and prolactin which is released by the pituitary gland. These
hormones stimulate the alveolar cells to divide and increase in number, which makes the
lobule enlarge. Without these hormones, the glandular cells, particularly the alveolar cells,
cannot survive, and undergo apoptosis which is programmed cell death. After
menopause, estrogen production stops, which leads to death of alveolar cells. Overtime,
the breast tissue gets replaced by fat. During the menstrual cycle, there’s increased
secretion of estrogen and progesterone from the ovaries, and right after menstruation,
that secretion decreases. As a result, during every menstrual cycle, the alveolar cells
undergo division and apoptosis. With more menstrual cycles, there is an increased risk
of tumor formation.

Once a cancer-causing mutation does occur, the affected cell, which is most
commonly an epithelial cell that lines the ducts or the lobules, begins to grow and replicate
out of control, forming a tumor. This tumor, also called in-situ carcinoma, is initially
localized within the basement membrane of the alveoli, and can be of two types. Ductal
carcinoma in-situ occurs when tumor cells grow from the wall of the ducts, into the lumen.
If left untreated, it can cross the basement membrane to become invasive ductal
carcinoma. Also, cancer cells may migrate alone the lactiferous duct and through the
pore, onto the skin over the nipple. As cancer cells move into the epithelium, there’s

33
inflammation which brings extracellular fluid out through breaks in the skin. This fluid then
dries and forms crusts over the skin surface.

On the other hand, lobular carcinoma in-situ bas clusters of tumor cells that grow
within the lobules, without invading the ducts, causing the affected alveoli to enlarge. LCIS
does not cross the basement membrane to form invasive lobular carcinoma. Some breast
cancer cells have hormone receptors that allow them to grow in the presence of the
hormones. Breast cancers can be divided into three major types- estrogen receptor or
ER-positive and HER2 -negative, HER-2 positive and ER-positive/ negative carcinoma
and ER-negative and HER2-negative carcinoma.

Complications may arise such as the tumor causes local inflammation which causes
damage to the suspensory ligaments and lactiferous ducts, resulting in their fibrosis. The
cancer can invade nearby tissues like the pectoral muscles and skin. Cancer cells can
also enter and block thin lymphatic vessels which causes lymph to build up in the
interstitial space. Normally, this fluid build-up would cause a swelling, but the attachment
of suspensory ligaments does not allow the skin to stretch. The skin becomes thickened
and dimpled like an orange peel, called peau d’orange appearance. The tumor cells now
spread via the blood to the spine, brain, lymph and bone as seen in the bone scan in
which multiple bone metastatic formation was found.

Cancer of the breast manifested clinically as a small, hard painless lump or swelling
which is commonly in the upper and outer part of the breast. Additionally, there may be a
swelling under the armpit, if cancer has spread to the axillary lymph nodes. The breast
becomes immobile and fixed due to infiltration. Dimpling of the skin over the breast is
seen. Patient also has nipple retraction or unusual discharge.

Due to the presence of breast mass, cancer cells may spread to the pleura or block
the change of flow of lymph fluid in the pleural cavity thus fluid shifted from semi-
permeable membrane and crossed in the pleura, hence being diagnosed with pleural
effusion. About 150 ml was seen through liver ultrasound with chest markings and was

34
about to undergo chest tube insertion but was resolved thereafter. This further
complicates the patients’ condition wherein signs of respiratory distress such as difficulty
of breathing, shortness of breath and orthopnea occurred. To determine metastasis in the
pulmonary area, chest x-ray was also facilitated but no pulmonary metastasis was seen.
However, bone scan was done and revealed multiple bony site metastasis therefore being
staged with breast cancer IV. The patient became depressed and therefore, did not have
the energy to eat thus malnutrition occurred as manifested by anemia and electrolyte
imbalance. Patient suddenly went into respiratory distress and was intubated and became
unresponsive with GCS of E3VTM4. Prolonged mechanical ventilation and hospitalization
may put the patient at risk for developing infection. Presence of infection associated with
hyperthermia; tachypnea may put the patient at risk for developing septic shock.

Multiple electrolyte imbalance such as hypokalemia may be due to presence of

insulin administration to facilitate shifting intracellular potassium. It is then associated with
hypernatremia due to sodium retention and inability of the kidneys to excrete excess
sodium in the body. Calcium on the other hand, increases due to ostelysis effect from
multiple bone metastasis.

VIII. Nursing Care Plan

The main identified nursing diagnosis for patient AAA is the risk for developing
septic shock. Septic shock is a severe and potentially fatal condition that occurs when
sepsis leads to life-threatening low blood pressure. Knowing how to assess presence of
septic shock is vital. Presence of infection with 2 SIRS criteria (Systemic Inflammatory
Response Syndrome) may cause severe sepsis leading to septic shock.

Assessment:
Patient AAA is unconscious and is intubated that is connected to mechanical
ventilator support with assist-control, pressure-control mode. She tolerated the current
setting therefore providing good ventilation and gas exchange. She has oropharyngeal
airway to maintain the mouth open. Loose and minimal whitish to greenish secretions are

35
present. However, her arterial blood gases show metabolic alkalosis and was managed
thereafter. It is also noted that there are present PMN> 10 in her endotracheal tube
indicating bacterial infection. She has nasogastric tube to draining bottle that causes her
to have multiple electrolyte imbalance (hypokalemia, hypernatremia, hypercalcemia). Her
vital signs are maintained as: BP: normotensive to a max of 165/90, bradycardic of 50s-
90s bpm, respiratory rate of 12-26 cpm and temperature with febrile episodes. Bilateral
upper lung lobe crackes and rhonchi can be heard and presence of bilateral metacarpal
and upper extremities presents non-pitting edema. There is a decrease urine output and
had an occasional hematochezia probably due to her hemorrhoids.

Nursing Diagnosis:
• Risk for infection
• Impaired gas exchange
• Imbalanced nutrition: Less than body requirement
• Risk for electrolyte imbalance
• Excess fluid volume
• Risk for ineffective peripheral tissue perfusion
• Risk for bleeding

Planning:
At the end of 4 day exposure, the patient will be able to:
1. Maintain temperature within the normal range
2. Prevent developing signs and symptoms of infection
3. Maintain WBC and differential count within acceptable levels
4. Maintain clear breath sounds
5. Return patients electrolytes back to normal levels
6. Prevent developing signs and symptoms of bleeding

Implementation:
It is important that infection prevention and control must be maintained all times. It
can be done through maintaining aseptic technique, providing VAP bundles of care,

36
nebulization, complying to turning schedules, and proper positioning. In relation to her
electrolyte management, administering appropriate electrolytes such as intravenous
potassium must be facilitated to prevent the development of cardiac dysrhythmias.
Adequate feeding must be done via nasogastric tube to facilitate nutritional support.
Administration of medication as indicated is necessary to facilitate symptom
management, however, since the patient is unconscious, it is important for us to consider
that even though she cannot verbalize presence of pain, administration of pain medication
must be done since she already presented with multiple bone metastasis.

Evaluation:
The care given to patient after 4-hours of planning was given to patient. Despite it
did not return back to the normal levels, care was focused on prevention of developing
into septic shock and was able at least return the intended outcome near the normal
desired values.

37
 IX. DRUG STUDY
Nursing Considerations for all drugs:
1. Ensure medications is administered to right patient, with right dose, time and route.
2. Assess patient before and after administration of medication.
3. Explain the desired effects of the medication and observe for side effects.
4. Document
5. Report any untoward side or adverse effect to physician.

Patient AAA

Generic Name, Action Indication for the Contraindication Side Effects Nursing Consideration
Dose, Frequency, patient
Route
Salbutamol Relieves nasal Risk for difficulty of Hypersensitivity to Nervousness, 1. Assess lung
nebulization every 4 congestion and breathing, adrenergic amines restlessness, sounds,
hours reversible bronchodilation and fluorocarbons tremor, respiratory rate,
Class: Bronchodilator bronchospasm by RR: 12-32 headache, pulse, blood
relaxing the smooth Breath sounds: (+) insomnia, pressure
muscles of the bilateral crackles chest pain, 2. Assess for
bronchioles. The at base of lungs palpitation, presence of
relief from nasal ABG: Partially angina, sputum
congestion and ompensated arrhythmias, 3. Ensure proper
bronchospasm is metabolic alkalosis hypertension, nebulization is
made possible by nausea and done
the following vomiting, 4. Monitor pulmonary
mechanism that hyperglycemia and function test
takes place. hypokalemia 5. Observe for
It binds to the beta 2 paradoxical
adrenergic receptors bronchospasm.
in the airway of the Notify physician
smooth muscle immediately
which then leads to
the activation of

38
 adenyl cyclase 6. Wash mouth with
increased levels of water to minimize
cyclic 3-5 adenosine dry mouth
monophosphate;
cAMP increases,
kinases are
activated; kinases
inhibit the
phosphorylation of
myosin and
decrease
intracellular calcium;
decreased in
intracellular calcium
will result to the
relaxation of the
smooth muscle
airways
Piperacillin- Antipseudomonal -Management of Hypersensitivity to Headache, 1. Assess presence
tazobactam 4.5 penicillin plus beta- pneumonia and penicillin insomnia, of sensitivity or
grams every 6 hours lactamase inhibitor; prevent further Drug allergies, agitation, allergic reaction
IV inhibits biosynthesis infection bleeding tendencies, fever, 2. Administer drug
Class: Extended of cell wall uremia, hypokalemia dizziness, per slow infusion
spectrum penicillin mucopeptide anxiety, via soluset (2-4
synthesis by binding hypertension, hours), may cause
to 1 or more of the tachycardia, irritation/ phlebitis
penicillin-binding chest pain, 3. Obtain blood CS
proteins and is edema, studies
effective during diarrhea, 4. Monitor hepatic,
active-multiplication nausea, renal and
stage constipation, hematopoetic
vomiting, function
dyspepsia,

39
 stool changes, 5. Monitor hydration
abdominal pain, status
thrombocytopenia,
dyspnea
Insulin Humulin R 4 Regulates glucose -To control and Hypersensitivity to Confusion, 1. Monitor blood
units as needed if metabolism, insulin prevent beef, pork, zinc, Agitation, sugar 1-2 hours
CBG > 180mg/dl and its analogues hyperglycemia protamine insulins tremors, pre-meals or after
subcutaneously, lower blood glucose with fast acting headache, meals. Ask
defer if CBG by stimulating insulin flushing, patients’ last meal
<90mg/dl peripheral glucose -To lower blood hunger, (time and meal)
Class: Insulin uptake, especially b sugar weakness, 2. Monitor mental
skeletal and fat, and Capillary blood lethargy, status/ presence
by inhibiting hepatic glucose trends: fatigue, of diaphoresis or
glucose production; 126-186 max CBG urticaria, signs and
insulin inhibits redness, symptoms of
lipolysis and irritation or swelling hypoglycemia/
proteolysis and at injection site, hyperglycemia
enhances protein tachycardia, 3. Assess presence
synthesis; targets palpitations, of dextrose
include skeletal hypoglycemic containing IV
muscle, liver and reaction, fluids, may affect
adipose tissue rebound blood sugar levels
hyperglycemia, 4. Give medication
lipodystrophy, pre-meals as
shock, ordered
anaphylaxis 5. Administer
medication
properly
6. Rotate sites of
injection to avoid
lipodystrophy
7. Assess patients’
commitment to

40
 insulin regimen if
indicated as home
medication
Teach patient how
to check blood
sugar and
administer insulin
Omeprazole 40mg IV Proton pump -To prevent Hypersensitivity, Headache, 1. Take medication
once a day inhibitor, binds to development of pregnancy, lactation dizziness, before meals
Class: Proton pump Hydrogen/Potassium ulcer asthenia, 2. Assess patients
inhibitor exchanging ATPase -To prevent gastric vertigo, gastric status prior
in gastric parietal upset insomnia, to administration
cells, resulting in -Presence of apathy, 3. Assess gastric
suppression of basal hematochezia anxiety, output and stool
and stimulated acid paresthesia, before and after
secretions rash, administration
inflammation,
urticaria,
pruritus,
alopecia,
dry skin,
diarrhea,
abdominal pain,
nausea,
vomiting,
constipation,
dry mouth,
tongue atrophy,
URTI symptoms,
cough,
epistaxis

41
Furosemide 40mg Loop diuretic; -To prevent Hypersensitivity, Dizziness, 1. Assess fluid status
every 8 hours IV as inhibits reabsorption congestion anuria, hepatic coma, encephalopathy, during therapy
needed for of sodium and -(+) bilateral severe hypokalemia headache, 2. Monitor blood
congestion chloride ions at crackles at bases or hyponatremia, insomnia, pressure and heart
Class: Loop diuretic proximal and distal of lungs hypovolemia with or nervousness, rate
renal tubules and (+) exertional without hypotension, hearing loss, 3. Monitor weight,
loop of Henle; by dyspnea tinnitus, intake and output
interfering with (+) use of hypotension, 4. Monitor for
chloride-binding accessory muscles photosensitivity, presence of
cotransport system, -RR: 12-32 cpm rashes, edema, lung
causes increases in -HR: 98-110bpm hyperglycemia, sounds, skin
water, calcium, -Oxygen saturation dehydration, turgor, mucous
magnesium, sodium 92% with episodes hypokalemia, membranes
and chloride of desaturation 85- hypomagnesemia, Monitor electrolytes
90% hyponatremia, (sodium, potassium),
-(+) orthopnea hypovolemia, renal and hepatic
-(+) distended, metabolic alkalosis, function, serum glucose
round, hard blood dyscrasias, and uric acid levels
abdomen hyperglycemia,
hyperuricemia,
arthralgia,
muscle cramps,
myalgia,
increased BUN
Oral Potassium Essential in To increase serum Hypersensitivity Arrythmias 1. Assess potassium
chloride 10% solution physiologic process potassium. Untreated Addison’s Bleeding levels prior and after
30cc every 6 hours Treatment of disease Diarrhea administration
per NGT x 4 doses hypokalemia Hyperkalemia Dyspepsia 2. Oral potassium
Class: Electrolyte Serum K+: 2.2-3.3 Concomitant use with Hyperkalemia chloride is irritant to the
supplements mmol/L triamterene and Nausea gastrointestinal tract and
amiloride Rash high local concentrations
Renal failure Vomiting can lead to ulceration.
Dilute the solution such

42
 as 20meq is contained in
at least 120ml of water or
juice.
3. Assess signs and
symptoms of
hypokalemia (ECG
changes, prominent u
wave, weakness, fatigue)
Potassium chloride Essential in To increase serum Hypersensitivity Arrythmias 1. Assess potassium
40meqs IV (in physiologic process potassium. Untreated Addison’s Bleeding levels prior and after
PNSS1L) x 8 hours Treatment of disease Diarrhea administration
infusion x 2 cycles hypokalemia. Hyperkalemia Dyspepsia 2. Assess signs and
and Serum K+: 2.2-3.3 Concomitant use with Hyperkalemia symptoms of
20meqs IV in PLR mmol/L triamterene and Nausea hypokalemia (ECG
100 ml x 5 hours x 2 amiloride Rash changes, prominent u
cycles and 20meqs in Renal failure Vomiting wave, weakness, fatigue)
PNSS 90 cc x 5 3. Ensure that
hours x 4 cycles intravenous potassium
Class: Electrolyte chloride should be given
supplements via infusion mixed with
appropriate intravenous
fluids.
4. DO NOT GIVE IV
PUSH
5. Assess patency of
intravenous line prior to
administration
6. Ensure cardiac
monitor/ ECG is attached
to patients chest
Tranexamic acid Inhibits fibrinolysis To prevent Hypersensitivity Visual abnormalities 1. Monitor for signs and
500mg every 8 hours by displacing bleeding Acquired defective Hypotension symptoms of bleeding
color vision Nausea and vomiting

43
IV as needed for plasminogen from Subarachnoid Diarrhea 2. Monitor heart rate and
bleeding fibrin hemorrhage Anaphylaxis blood pressure
Class: Antifibrinolytic Reduces plasmin Active intravascular 3. Monitor complete
agent activity, which in turn clotting blood count levels
reduces activation of 4. Document time
complement and bleeding started and
consumption of c1 stopped. Take note of the
esterase inhibitor estimated or if possible
(C1-NH) and the exact amount of
subsequently blood loss if any
decreases
inflammation
associated with
hereditary
angioedema
Vitamin K 10 mg Promotes hepatic -To prevent risk for Biliary tract disease Anaphylaxis 1. Monitor baseline
every 8 hours IV synthesis of clotting bleeding Hepatic disease Dyspnea values of PT/PTT/INR
Class: Hemostatic factors II, VII, IX, X -Patient has Jaundice Cyanosis and then after
prolonged PT/PTT Hypoprothrombinemia Erythematous skin administration
Thromboembolic eruption 2. Assess for decreased
disease Pruritus in blood pressure,
Anticoagulant therapy Scleroderma-like increase in heart rate and
Pregnancy lesions abdominal pain
Breast feeding Flushing
Hypotension
Injection site reaction
Olmesartan + Olmesartan is an -To manage and Hypersensitivity Drowsiness 1. Monitor blood pressure
amlodipine 20/5mg/ angiotensin II control Pregnancy Swelling before and after
tab 1 tab OD per receptor antagonist. hypertension that Anuria Flushing administration
NGT It keeps blood is not controlled Hypotension Hair loss 2. Monitor heart rate and
Class: Angiotensin vessels from with one of the Skin rash palpitations, signs and
receptor blocker + narrowing which components within symptoms of hypotension
lowers blood the same

44
Calcium channel pressure and antihypertensive (lightheadedness or
blocker improves blood flow. class dizziness)
-Inhibits BP: increases up 3. May take medication
transmembrane to 165/90 without food
influx of extracellular
calcium ions across
membranes of
myocardial cells and
vascular smooth
muscle cells without
changing serum
calcium
concentrations; this
inhibits cardiac and
vascular smooth
muscle contraction,
thereby dilating main
coronary and
systemic arteries
Carvedilol 25mg/tab Nonselective beta- -To manage and Hypotension Dizziness 1. Monitor blood pressure
1 tab OD per NGT adrenergic and control 2nd- 3rd degree AV Fatigue before and after
Class: Beta blocker alpha 1-adrenergic hypertension block Hypotension administration
blocking agent with BP: increases up Sick sinus syndrome Weight gain 2. Monitor heart rate and
no intrinsic activity to 165/90 Severe bradycardia Hyperglycemia palpitations, signs and
for use in congestive Severe Bradycardia symptoms of hypotension
heart failure and decompensated heart Nausea (lightheadedness or
hypertension failure Headache dizziness)
3. May take medication
without food
Tamoxifen 200mg/tab Selective estrogen -Patient has breast Anticoagulant therapy Increased tumor or 1. Monitor for signs of
1 tab OD per NGT receptor modulator: cancer stage IV Chemotherapy bone pain nausea
Class: Antineoplastic non-steroid with Stroke Nausea 2. Monitor for signs of
potent Thromboembolism Fatigue abnormal vaginal

45
 antiestrogenic Anemia Mood swings bleeding, changes in
effects in breast; has Cataracts Depression vaginal discharge or
cytostatic effect Headache lower abdominal pain
rather than cytoidal Hair thinning may suggest presence of
effects. endometrial cancer

Celecoxib 200mg/cap Inhibits -To alleviate pain Hypersensitivity Headache 1. Monitor for signs of
1 cap BID for pain cyclooxygenase-2, Asthma Hypotension gastrointestinal bleeding
Class: NSAIDs does not affect Urticaria Fever 2. Take with food
COX-1 thereby Anaphyactoid Athralgia 3. Since patient had
decreasing Cough signs of hematochezia, it
formation of Vomiting was discontinued to
prostaglandin Diarrhea prevent bleeding
synthesis GERD tendencies.
Sinusitus
Enoxaparin 0.4 cc LMWH is an -It is given for Thrombocytopenia Hemorrhage 1. Assess for presence of
OD SC antithrombotic that deep vein Idiopathic Elevation of serum bleeding, bruising and
Class: Anticoagulant inhibits factor Xa by thrombosis thrombocytopenic aminotransferases ecchymoses
increasing inhibition prophylaxis since purpura Fever 2. Monitor for skin
rate of clotting the patient is Active bleeding Local site reaction necrosis
proteases that are immobile. Thrombocytopenia 3. Monitor laboratory
activated by Nausea values of PT/PTT/INR
antithrombin III Anemia 4. Since the patient had
signs of hematochezia, it
was discontinued and
shifted to rivaroxaban
Rivaroxaban Factor Xa inhibitor -It is given for Bleeding Abdominal pain 1. Assess for presence of
15mg/tab 1 tab BID that inhibits platelet deep vein Anticoagulant therapy Back pain bleeding, bruising and
per NGT activation by thrombosis Renal failure Blister ecchymoses
Class: Anticoagulant selectively blocking prophylaxis since Coagulopathy Bruising 2. Monitor for skin
the active site of the patient is Abrupt Constipation necrosis
factor Xa without immobile. discontinuation Epistaxis 3. Monitor laboratory
Dyspepsia values of PT/PTT/INR

46
requiring a cofactor Fatigue 4. Must be taken with
for activity. Headache meals prior to
Blood coagulation Nausea administration
cascade is Hematuria
dependent on the Muscles spasm
activation of factor X
to factor Xa via the
intrinsic and extrinsic
pathways, which
play a central role in
the blood
coagulation cascade

47
48
XI. Health Instructions:

Medication:
Current medications that patient AAA is taking in-hospital. It is important to ensure
that the patient will take all the necessary medications as indicated. Since the nurse is
the primary care giver, it is important he/ she is knowledgeable regarding assessment
and early recognition of desired and side effects to correlate it to the clinical and
diagnostic findings.

Exercise:
Patient AAA is immobile so it is important to collaborate management with the
physical therapist to provide passive range of motions and appropriate exercises. If able,
the relatives and caregivers may participate in providing passive exercise to the patient,
hence preventing development of edema and deep vein thrombosis.

Treatment:
Patient is currently managed with advanced airway mechanical ventilation and
antineoplastic drug (chemotherapy) for her cancer. It is important to know the progress of
the treatment so that adjustments if applicable may be made. The patient is not scheduled
for any other treatment such as surgery.

Home Environment
Since the patient is currently admitted, manipulation of her environment such as
adequate lighting, ventilation and noise may affect the quality of her development. It is
important as well that all emergency supplies and equipment is readily available in case
the patients case deteriorates.

OPD follow-ups
There is no follow-up schedule for this patient.

49
Diet
The patient is taking milk per drip feeding per nasogastric tube. After tolerating the
milk drip feed, she may be referred to a dietitian for computation of osteorized feeding
depending on her metabolic needs. Since she is hypertensive, even osteorized food may
have a decrease in sodium content.

Spirituality
Involving her relatives to pray for her and determining if the relatives wants her to
be anointed by the priest since they are catholic.

XII. Conclusion and Recommendation:

Chronic illness such as being diagnosed with cancer is very difficult to deal with. As
an advanced practice nurse, it is important that the 5 competencies according to
Nieminen, (2012) must be observed to further increase clinical competencies and at the
same time delivering quality care to patients. Being able to assess patients’ caring needs,
developing a caring relationship, practicing multi-professional teamwork, developing
competence in nursing care and leadership in learning and caring culture is important.
Even though our patients are conscious or unconscious, they deserve the best quality
care anyone should have. Giving my best to develop an appropriate plan of care and
applying it not only to my patient but as well as my other patient grounded by theories will
enable me to be an efficient and effective nurse.

Multi-organ dysfunction is not easy to manage, however, with the help of other
professionals, and having the same goals in handling patients will definitely have a good
outcome.

XIII. References:
Primary source: Patient (non-verbal), chart
Secondary source: Patient chart, sisters

50
Brunner, L. S., Suddarth, D. S., Smeltzer, S. C. O., & Bare, B. G. (2004). Brunner &
Suddarth's textbook of medical-surgical nursing (10th ed.). Philadelphia: Lippincott
Williams & Wilkins.
Kee, J. L., Hayes, E. R., & McCuistion, L. E. (2006) Pharmacology: A Nursing Process
Approach (5th ed.). Singapore: Elsevier.
Medscape (2019). Medscape WebMD LLC. [Mobile application software]. Retrieved from
http://play.google.com/store
MIMS Philippines (2018). MIMS Drug Refence: Concise Prescribing Information (155 th
ed.). Singapore
https://www.cancer.org/content/dam/cancer-org/research/cancer-facts-and-
statistics/breast-cancer-facts-and-figures/breast-cancer-facts-and-figures-2019-2020.pdf
https://www.who.int/cancer/PRGlobocanFinal.pdf
https://www.who.int/news-room/fact-sheets/detail/cancer
https://www.openanesthesia.org/modes_of_mechanical_ventilation/
https://www.medicine.mcgill.ca/physio/vlab/bloodlab/PT_PTT.htm

51
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