La Consolacion College of Daet, Inc.

F. Pimentel Avenue, Daet, Camarines Norte, Philippines 4600

Tel. No. (054) 721-2181 / 440-2002 Fax No. (054) 571-3467

BREAST CANCER STAGE IV

A Case Study Presented to

the Faculty of

La Consolacion College of Daet, Inc.

As partial fulfilment of

The requirements for First Semester of

Bachelor of Science in Nursing III

RUZOL, Julie Anne T.

SALEN, Fiona C.

SUINAN, Czarina Ley T.

TALANQUINES, Marjorie B.

TATING, Janella A.

VILLAGARCIA, Jester O.

VILLAGRACIA, Arabelle R.

VILLAREAL, Janela Rose A.

YARTE, Natasha Darian S.

YONCGO, Shane Cathryn B.

DECEMBER 2023
Table of Contents

Title 1

Introduction 3

History of Past and Present Illness 3

Assessment 4

Nursing Theory 7

Theoretical Paradigm 8

Review of Anatomy and Physiology 9

Pathophysiology 20

Laboratory and Diagnostics 22

Course in the Ward 24

Drug Study 27

Nursing Care Plan 47

Discharge Plan 62
 I. Introduction:

Breast cancer is the most common cancer diagnosed in women, accounting for one out
of every ten new cases diagnosed each year. It is the second most frequent cause of cancer-
related deaths among women worldwide. There were 27,163 cases of breast cancer recorded in
the country in 2020, while 9,926 Filipino women died of the disease (Philippine Institute for
Development Studies, 2023). Breast cancer is a disease in which abnormal breast cells grow
out of control and form tumours. If left unchecked, the tumours can spread throughout the
body and become fatal. Cancer cells begin inside the milk ducts and or the milk-producing
lobules of the breast. The earliest form (in situ) is not life-threatening. Cancer cells can spread
into nearby breast tissue, this creates tumours that cause lumps or thickening. Cancers that
invade organs have the ability to metastasis, or spread to neighboring lymph nodes. Fatal
metastases are possible.

Males account for 1% of cases of breast cancer, with women making up the majority. A
woman's risk of developing breast cancer increases if she had menstruated before the age of
twelve, went through a late menopause after the age of fifty-five, did not give birth or
breastfeed, had a family history of the disease lymphoma, used birth control pills excessively, or
had hormone replacement treatment (City of Hope, 2023). Research indicates that there is
still a lack of clarity regarding the associations between breast cancer risk factors and tobacco
use, diet and vitamin intake, pollutants in the environment, night employment, antiperspirant
usage, tight bra use, and breast implants.

This case presents a history of a 50-year-old female with a chief complaint of abdominal
pain upon admission. The admitting diagnosis is Breast Cancer with Probable Metastasis to
Liver. Later on, Breast Cancer Stage IV became a part of the diagnosis. The purpose of this
study is to analyse various etiologies that could lead to breast cancer, discuss the results of
physical examination and laboratory analysis, and review the nursing and medical care provided
to the patient who had breast cancer.

II. History of Past and Present Illness

a) Patient’s Data

Patient’s Name : Patient X

Address : Purok 1, San Antonio, Labo, Camarines Norte
Sex : Female
Birthdate : December 4, 1972
Age : 50
Birthplace : Labo, Camarines Norte
Religion : Roman Catholic
Civil Status : Married
Admission Date : September 27, 2023
Admission Time : 1:45 PM
Admitting Diagnosis : Breast Cancer with Probable Metastasis to Liver
Principal Diagnosis : Breast Cancer Stage IV
Date of Discharge : October 4, 2023
Time of Discharge : 10:45 PM
Admitting Physician : Dr. Rance B. de los Santos
Chief Complaint : Started with abdominal pain frequented to Emergency Room for
Admission

b) Medical History

History of Present Illness

Mrs. X, a 50-year-old woman, reported to the hospital with abdominal pain and
abdominal enlargement, is known to have breast cancer (left), and probable metastasis to liver
and lungs. She is also known as a chemotherapy outpatient. She is known to have lupus since
2020. At the triage, the patient’s vital signs were checked and recorded as follows: blood
pressure was 90/60 mmHg, cardiac rate was 107 bpm, respiratory rate was 23 bpm, SPO2 was
97%, temperature was 36.1 °C, weight of 41 kilograms and height was 157 cm.

Past Medical History

(+) Lupus 2020
(+) Breast CA Stage 3A (February 2021)
(-) Allergies
(-) Smoking and alcohol consumption

Family History
No family history of breast cancer and other type of cancer

III. Assessment

The patient is a 50-year-old female who resides in Purok 1, San Antonio, Labo,
Camarines Norte. She was admitted last September 27, 2023 at 1:45 PM in Camarines Norte
Provincial Hospital to the emergency room via stretcher due to abdominal pain and abdominal
enlargement. She was seen by Dr. de los Santos and instructed the attending nurses to monitor
her vital signs – blood pressure, heart rate, respiratory rate, and temperature. For further
monitoring and evaluation, the patient was referred to an oncologist.

a) Physical Exam

General Survey:
Vital Signs:
Blood Pressure : 90/60 mmHg
Cardiac Rate : 107 bpm
Respiratory Rate : 23 bpm
Temperature : 36.1 ℃
O2 Saturation : 97%
Weight :41 kg
Height : 157 cm

HEENT/Skin : Yellowish skin discoloration and sclera

Chest/Lungs : Essentially Normal
Heart : Essentially Normal
Abdomen : Enlarged Abdomen
GU (IE) : Essentially Normal
Skin/Extremities : Bipedal edema
Neurological : GCS – 15

b) Gordon’s functional pattern

Pattern Before During Analysis

Hospitalization Hospitalization
Health Perception The patient receives The guardian claimed They showed
Pattern her chemotherapy at that regular check- compliance to
Bicol Medical Center. ups are important to treatment regimen
She had 22 cycles of assess the overall and prescriptions
chemotherapy for 2 health status of the provided for the
years. Every month patient. She was management of the
after the treatment confined at health condition of
she receives check- Camarines Norte the client.
up. Provincial Hospital –
Private Ward last
September 27, 2023
until October 5, 2023.
Nutritional The guardian stated Upon confinement, The metabolic needs
Metabolic that the patient eats the client was not of the client are only
three meals a day, able to eat well. It compensated by
only in small amount. became to the point intravenous therapy
Her source of water that her only meal and small amount of
is mineral and tap was oatmeal or food and liquid which
water. “lugaw” because are not enough
these two are what nutrients to supply
her stomach only the body and
accepts. The replenish its needs.
guardian claimed
that, in small amount
of food, the patient is
full already.
Elimination Before confinement, The guardian claimed While she was
Pattern the guardian claimed that the urine output confined, her bowel
that the patient is highly colored and and urinal
seldom defecates. has a foul-smelling movements changed
odor. “Masusuka ka in volume and
sa amoy,” as frequency.
verbalized.
Activity/Exercise The patient was an The patient is She was subjected to
Pattern elementary teacher. bedridden. She has rigid restrictions due
She was diagnosed bipedal edema. to her condition.
with lupus in 2020,
later on February
2021, breast cancer
became a part of
diagnosis.
Sleep/Rest Pattern Before confinement, During confinement, The patient’s
the patient was not the patient was able condition and
able to sleep and rest to sleep and rest environment are
as she experiences because of the huge factors that
abdominal pain, management given to affects her rest and
nausea, and her by the nurses and sleep pattern.
vomiting. She is only the doctor.
able to sleep and rest
when the pain
subsides or when
morning comes.
Cognitive- The patient was an The guardian claimed The patient
perceptual Pattern elementary teacher that the client is experiences chronic
for 10 years. strong. She was able pain because of her
to fight her disease illness. Several
until the end, and complications arise as
they were willing to adverse effect of her
travel and spend just treatment.
for her treatment.
The patient
experiences chronic
pain due to her
illness.
Self-perception/ The guardian viewed the client as a nice and Illness, trauma, and
Self-concept generous person. They also believed that the medical conditions
Pattern client is kind-hearted and has a good heart. can both affect one’s
“Kahit saan, marami yan kakilala,” was perception or self-
verbalized. concept.

Role-relationship The patient has a The guardian was They felt sad and
Pattern husband and a anxious and underwent grief as
 mother of three. She disappointed they had not
is claimed to be as a regarding the anticipated the loss
nice and generous condition the client. of their loved one.
person. She gets
along well with
people surrounding
her.
Sexuality/ The patient has a husband and a mother of Sexuality and
Reproductive three. reproductive patterns
Pattern are affected by the
changes that occur in
a person's body or
person’s life.
Coping/Stress Before During confinement, The patient’s coping
Tolerance Pattern hospitalization, the the guardian claimed mechanism before
client’s coping that Patient X also and during her
mechanism is to sleeps, as a response hospitalization are
sleep, as a response to stress stimuli. the same.
to stress stimuli.

Value/Belief The guardian stated Their faith in God Religious activity and
Pattern that their religion is does not change and beliefs may have an
Roman Catholic. they believe that impact on a patient's
Although the patient “prayer works”. She life.
did not have time to is a strong believer
attend to mass, she and is God-centered.
reads the bible and
prays the rosary.

IV. Nursing Theory

Sister Callista Roy

Adaptation Model

According to Roy Adaptation Model, the aim of nursing is to increase compliance and life
expectancy. Roy Adaptation Model evaluates the patient in physiologic mode, self-concept
mode, role function mode and interdependence mode aiming to provide holistic care. This
section describes the use of Roy Adaptation Model in the care of a patient who has been
diagnosed with Stage IV Breast Cancer with Liver Metastasis.

In Roy’s Adaptation Model, nurses consider the whole person and their surrounding
environment when treating patients. The model can be applied to a patient facing terminal
illness to help them feel comfortable and at peace as they prepare for the end of their life.
Sister Callista Roy’s Adaptation Model focuses on changes experienced by human beings as they
respond to environmental stimuli to maintain their integrity. The goal of Roy’s Adaptation Model
nursing is promotion of an integrated level of adaptation for individuals and groups that can
advance wellness, the quality of life and death with dignity.

V. Theoretical Paradigm

Conceptual Framework of
Sister Callista Roy’s Adaptation Model

VI. Review of Anatomy and Physiology

Anatomy and Physiology of the breast

 The anatomy of the breast must be well
understood to understand the disorders that affect
this organ and develop a plan for breast surgery.
When examined, some degree of asymmetry is noted
in most breasts. Other deformities include kyphosis,
scoliosis, or some type of pectus deformity.

The majority of the breast consists of glandular (milk-

producing) and fatty tissues. However, the ratio of
the glandular to fatty tissue varies among individuals.
The breast is heavily influenced by the sex hormone
estrogen. As menopause approaches, the levels of
estrogen declines which also decreases the glandular
tissues.

The pectoralis major muscle forms the

base of the breast, which extends from the
second to sixth rib early in life but may extend to
below the sixth rib as the breast matures and
sags. The breast is anchored to the pectoralis
major fascia by the Cooper ligaments. However,
these ligaments are flexible and allow for
movements in the breast. In most women, the
Cooper ligaments become stretched with time
and age, eventually resulting in a ptotic breast.
Because of gravity, the lower pole of the breast
is fuller than the upper pole. At the lateral edges
of the breast, the tail of Spence extends in the
axilla.
The nipple is usually located just superior to the
infra-mammary crease and is consistently found level along the midclavicular line and the fourth
rib.

The underlying breast is made of glandular (milk-producing) and fatty tissue. The ratio
of fat versus glandular varies depending on age, post-menopausal, post-partum, or pregnancy
status. At the onset of menopause, a decline in the levels of estrogen results in a decrease in
glandular tissue and an increase in fatty tissue.

The nipple plays an important role in breastfeeding. The minimal nipple length required
for successful breastfeeding is about seven millimeters. However, the nipple shows great
variation in topography; it can be flat, short, and even inverted, which can hamper
breastfeeding in some women.

Anatomy and Physiology of the Liver

 The liver is located in the upper
right-hand portion of the abdominal cavity,
beneath the diaphragm, and on top of the
stomach, right kidney, and intestines.
Shaped like a cone, the liver is a dark
reddish-brown organ that weighs about 3
pounds. There are 2 distinct sources that
supply blood to the liver, including the
following:
 Oxygenated blood flows in
from the hepatic artery
 Nutrient-rich blood flows in
from the hepatic portal vein

The liver holds about one pint (13%) of

the body's blood supply at any given moment.
The liver consists of 2 main lobes. Both are
made up of 8 segments that consist of 1,000
lobules (small lobes). These lobules are
connected to small ducts (tubes) that connect
with larger ducts to form the common hepatic
duct. The common hepatic duct transports the
bile made by the liver cells to the gallbladder
and duodenum (the first part of the small
intestine) via the common bile duct.

The liver regulates most chemical levels in the

blood and excretes a product called bile. This
helps carry away waste products from the liver.
All the blood leaving the stomach and intestines
passes through the liver. The liver processes
this blood and breaks down, balances, and creates the nutrients and also metabolizes drugs
into forms that are easier to use for the rest of the body or that are nontoxic. More than 500
vital functions have been identified with the liver. Some of the more well-known functions
include the following:
 Production of bile, which helps carry away waste and break down fats in the small
intestine during digestion
 Production of certain proteins for blood plasma
 Production of cholesterol and special proteins to help carry fats through the body
 Conversion of excess glucose into glycogen for storage (glycogen can later be converted
back to glucose for energy) and to balance and make glucose as needed
 Regulation of blood levels of amino acids, which form the building blocks of proteins
  Processing of hemoglobin for use of its iron content (the liver stores iron)
 Conversion of poisonous ammonia to urea (urea is an end product of protein metabolism
and is excreted in the urine)
 Clearing the blood of drugs and other poisonous substances
 Regulating blood clotting
 Resisting infections by making immune factors and removing bacteria from the
bloodstream
 Clearance of bilirubin, also from red blood cells. If there is an accumulation of bilirubin,
the skin and eyes turn yellow.

When the liver has broken down harmful substances, its by-products are excreted into
the bile or blood. Bile by-products enter the intestine and leave the body in the form of feces.
Blood by-products are filtered out by the kidneys, and leave the body in the form of urine.

Anatomy and Physiology of the Kidney

The kidneys are two bean-shaped organs

that filter blood. The kidneys are part of the urinary
system. The kidneys filter about 200 quarts of fluid
every day — enough to fill a large bathtub. During
this process, kidneys remove waste, which leaves
your body as urine (pee). Most people pee about
two quarts daily. The body re-uses the other 198
quarts of fluid. They also help balance your body’s
fluids (mostly water) and electrolytes. Electrolytes
are essential minerals that include sodium and
potassium.

Kidneys toxins and waste out of the blood.

Common waste products include nitrogen waste
(urea), muscle waste (creatinine) and acids. They
help the body remove these substances. The
kidneys filter about half a cup of blood every
minute.

The renal artery

most people at rest, the renal kidneys pump a
little over 5 cups (1.2 liters) of blood to the
kidneys each minute. The outer layer of the
kidney, where the nephrons (blood-filtering
units) begin. The renal cortex also creates the
hormone erythropoietin (EPO), which helps
make red blood cells in the bone marrow. The
renal medulla is the inner part of the kidney. It
contains most of the nephrons with their
glomeruli and renal tubules. The renal tubules
carry urine to the renal pelvis. These pyramid-shaped structures transfer urine to the ureters.
Dehydration and certain medications — especially nonsteroidal anti-inflammatory drugs
(NSAIDs) — may damage your renal papilla.
This funnel-shaped structure collects urine and passes it down two ureters. Urine travels from
the ureters to the bladder, where it’s stored. This vein is the main blood vessel that carries
filtered blood out of the kidneys and back to the heart. Each of the kidneys has a renal vein.

Anatomy and Physiology of the Skin

The human skin is divided into

three main layers: the epidermis,
dermis, and subcutaneous
tissue. The dermis and epidermis
are separated by a structure called
the basement membrane. The
thickness of skin varies depending
on the location of the body and is
primarily determined by the
varying thickness of either the
dermis or epidermis.

The epidermis is the avascular

outermost layer of the skin. It is
composed of keratinocytes and
dendritic cells. Keratinocytes are
the predominant cell type found in
the epidermis, accounting for over
90% of all cells in the epidermis.
They play an important role in the function of the skin as a protective barrier and through
epithelization, restore the integrity of the skin during wound healing. Dendritic cells, on the
other hand, play an important role in the immune system.

The epidermis is further subdivided into five layers. These skin anatomy layers are as
follows: stratum corneum, stratum lucidum, stratum granulosum, stratum spinosum, and
stratum basale.

The dermis is the thickest, vascular layer of the skin. Unlike the epidermis which contains
keratinocytes, the dermis is populated with fibroblasts and contains vasculature and innervation
of the skin. The thickness of the dermis varies depending on the location of the body which also
results in differences in the thickness of the skin. The blood vessels in the dermis are
responsible for maintaining homeostasis, providing nutritional support, and thermoregulation.
Even though the blood vessels do not enter into the epidermis, the cells of the epidermis
derived their oxygen and nutrients brought by the vasculature in the dermis through simple
diffusion.

The dermis has two layers: the thin outer layer called the “papillary dermis” and a deeper
thick layer called the “reticular dermis”. Indenting into the overlying epidermis, there are peg-
like projections on the outer surface of the papillary dermis called “dermal papillae”. Dermal
papillae might contain blood vessels, free nerve endings, and touch receptors.

The reticular dermis, unlike the papillary dermis which contains loose areolar tissue,
contains dense connective tissue. It contains thick bundles of collagen fibers and accounts for
over 80% of the total thickness of the dermis. Unlike the epidermis and dermis which are
separated by a basement membrane, there is no clear demarcation between the papillary and
reticular dermis.

The hypodermis, or the subcutaneous tissue, is the bottom-most layer of skin and lies just
below the dermis. It is primarily composed of adipose tissue and helps to attach the dermis to
the underlying structures where the hair follicles lie. The hypodermis acts as an insulator, and
an energy reservoir, and provides cushioning to the skin.

Skin is one of the largest, visible organs in the human body. Several medical conditions can
have cutaneous manifestations and can provide clinicians with an important clue regarding their
diagnosis. Skin performs several important functions for the human body, Protection,
thermoregulation, sensation and metabolism. An understanding and appreciation of these
functions can help clinicians better address the impact of skin pathologies.

Anatomy and Physiology of the Brain

The brain is an amazing three-pound organ that controls all functions of the body,
interprets information from the outside world, and embodies the essence of the mind and soul.
Intelligence, creativity, emotion, and memory are a few of the many things governed by the
brain. Protected within the skull, the brain is composed of the cerebrum, cerebellum, and
brainstem.

The brain receives information through our five senses: sight, smell, touch, taste, and
hearing - often many at one time. It assembles the messages in a way that has meaning for us,
and can store that information in our memory. The brain controls our thoughts, memory and
speech, movement of the arms and legs, and the function of many organs within our body.

The central nervous system (CNS) is composed of the brain and spinal cord. The
peripheral nervous system (PNS) is composed of spinal nerves that branch from the spinal cord
and cranial nerves that branch from the brain.

The brain is composed of the cerebrum, cerebellum and brainstem.

Cerebrum: is the largest part of the brain and is composed of right and left hemispheres. It
performs higher functions like interpreting touch, vision and hearing, as well as speech,
reasoning, emotions, learning, and fine control of movement.

Cerebellum: is located under the cerebrum. Its function is to coordinate muscle movements,
maintain posture, and balance.

Brainstem: acts as a relay center connecting the cerebrum and cerebellum to the spinal cord. It
performs many automatic functions such as breathing, heart rate, body temperature, wake and
sleep cycles, digestion, sneezing, coughing, vomiting, and swallowing.

Right brain – left brain

The cerebrum is divided into

two halves: the right and left
hemispheres (Fig. 2) They are
joined by a bundle of fibers called
the corpus callosum that transmits
messages from one side to the
other. Each hemisphere controls the
opposite side of the body. If a
stroke occurs on the right side of
the brain, your left arm or leg may
be weak or paralyzed.
 Not all functions of the hemispheres are shared. In general, the left hemisphere controls
speech, comprehension, arithmetic, and writing. The right hemisphere controls creativity,
spatial ability, artistic, and musical skills. The left hemisphere is dominant in hand use and
language in about 92% of people.

The cerebral hemispheres have distinct

fissures, which divide the brain into lobes. Each
hemisphere has 4 lobes: frontal, temporal, parietal,
and occipital Each lobe may be divided, once again,
into areas that serve very specific functions. It’s
important to understand that each lobe of the brain
does not function alone. There are very complex
relationships between the lobes of the brain and
between the right and left hemispheres.

Frontal lobe - Personality, behavior, emotions,

judgment, planning, problem solving. Speech:
speaking and writing (Broca’s area), body movement
(motor strip), intelligence, concentration and self-
awareness.

Parietal lobe - Interprets language, words, sense of touch, pain, temperature (sensory strip),
interprets signals from vision, hearing, motor, sensory and memory, spatial and visual
perception

Occipital lobe - Interprets vision (color, light, movement)

Temporal lobe - Understanding language (Wernicke’s area), memory, hearing, sequencing and
organization.

In general, the left hemisphere of the brain is responsible for language and speech and
is called the "dominant" hemisphere. The right hemisphere plays a large part in interpreting
visual information and spatial processing. In about one third of people who are left-handed,
speech function may be located on the right side of the brain. Left-handed people may need
special testing to determine if their speech center is on the left or right side prior to any surgery
in that area.

Aphasia is a disturbance of language affecting speech production, comprehension,

reading or writing, due to brain injury – most commonly from stroke or trauma. The type of
aphasia depends on the brain area damaged.

Broca’s area: lies in the left frontal lobe. If this area is damaged, one may have difficulty
moving the tongue or facial muscles to produce the sounds of speech. The person can still read
and understand spoken language but has difficulty in speaking and writing ( i.e. forming letters
and words, doesn't write within lines) – called Broca's aphasia.
 Wernicke's area: lies in the left temporal lobe (Fig 3). Damage to this area causes
Wernicke's aphasia. The individual may speak in long sentences that have no meaning, add
unnecessary words, and even create new words. They can make speech sounds; however, they
have difficulty understanding speech and are therefore unaware of their mistakes.

Anatomy and Physiology of the Joints

A joint is a point where two bones make

contact. Joints can be classified either
histologically or functionally. Histological
classification is based on the dominant type of
connective tissue, and functional classification is
based on the amount of movement permitted.
Histologically the three joints in the body are
fibrous, cartilaginous, and synovial. Functionally
the three types of joints are synarthrosis
(immovable), amphiarthrosis (slightly
moveable), and diarthrosis (freely moveable).
The two classification schemes can be
correlated: synarthroses are fibrous,
amphiarthroses are cartilaginous, and
diarthroses are synovial.

Joints, comprising bones and connective

tissue, are embryologically derived from
mesenchyme. The bones either develop directly
through intramembranous ossification or
indirectly through endochondral ossification. Each specific joint has a unique vascular supply
and innervation scheme; patterns do exist. Muscles provide stability to joints, and there is a
direct correlation between muscle strength and joint stability, particularly with synovial joints.

Many pathophysiological conditions affect joints, and again, patterns exist by histological
class. Because diseases that affect the joints are common across the lifespan, a thorough
understanding of joint structure
and function is of great clinical
significance.

Anatomy and Physiology of

the Blood Cells

Blood is a connective tissue.

Like all connective tissues, it is
made up of cellular elements
and an extracellular matrix.
The cellular elements—referred
to as the formed elements—
include red blood cells (RBCs), white blood cells (WBCs), and cell fragments called
platelets. The extracellular matrix, called plasma, makes blood unique among connective
tissues because it is fluid. This fluid, which is mostly water, perpetually suspends the formed
elements and enables them to circulate throughout the body within the cardiovascular system.

The primary function of blood is to deliver oxygen and nutrients to and remove wastes
from body cells, but that is only the beginning of the story. The specific functions of blood also
include defense, distribution of heat, and maintenance of homeostasis.

Anatomy and Physiology of the Lungs

The lungs, which is the organ for respiration is a paired cone shaped organ lying in the
thoracic cavity separated from each other by the heart and other structures in the mediastinum.

Each lung has a base resting on the diaphragm and an apex extending superiorly to a
point approximately 2.5 cm superior to the clavicle. It also has a medial surface and with three
borders- anterior, posterior and inferior. The broad coastal surface of the lungs is pressed
against the rib cage, while the smaller mediastinal surface faces medially. The lungs receive the
bronchus, blood vessels, lymphatic vessels and nerves through a slit in the mediastinal surface
called the hilum, and the structures entering the hilum constitutes the lungs root.

The right lung is larger and weighs

more than the left lung. Since the
heart tilts to the left, the left lung is
smaller than the right and has an
indentation called the cardiac
impression to accommodate the heart.
This indentation shapes the inferior
and anterior parts of the superior lobe
into a thin tongue-like process called
the lingual
Anatomy and Physiology of the Heart

The heart is
organ of the circulatory system. The heart
contains four main sections (chambers) made of
muscle and powered by electrical impulses. The
brain and nervous system direct the heart’s
function.

The heart’s main

rhythm and speed of your heart rate and
maintains blood pressure.

The heart works

The
primary
systems are:

Nervous system: The nervous system helps control

heart rate. It sends signals that tell the heart to beat
slower during rest and faster during stress.

Endocrine system: The endocrine system sends out

hormones. These hormones tell the blood vessels to
constrict or relax, which affects blood pressure.
Hormones from the thyroid gland can also tell the heart
to beat faster or slower.
VII. Pathophysiology
Interpretation of the Pathophysiology
 Breast cancer, also known as breast carcinoma, is defined as the abnormal proliferation
of epithelial cells in the breast. Its abnormal growth can result in the formation of a tumor. A
tumor is a mass of abnormal tissue that can be benign, premalignant, or cancerous. Many
factors increase a person's risk of developing breast cancer, but the primary cause of its
occurrence is still unknown. A few risk factors include age, gender, family history, early
menarche, late menopause, obesity, and physical inactivity.

In this case, the patient was initially diagnosed with Breast Cancer Stage 3-A, but it
progressed to Stage IV and metastasized in her liver, as evidenced by her pathology report. The
patient's risk factors include her age (50 years old), gender, lifestyle, and lupus disease. The
patient has no history of breast cancer or any other type of cancer. Although there is no known
cause of breast cancer, the risk factors she possessed may have contributed to her developing
the disease. Where there is a genetic mutation in the cellular DNA and that mutation leads to
the inactivation of tumor suppressor genes, activation of growth-promoting oncogenes, and
alterations in the gene that controls apoptosis. These modifications cause abnormal cell
proliferation in the milk ducts, which results in the formation of a tumor, which subsequently
develops into a malignant tumor. The patient's breast size changed due to the continuous
growth of the malignant tumor, and she developed a lump in her breast, which became the
subject of a biopsy. As the malignant tumor increases, it causes rapid multiplication of cancer
cells, and due to the rapid multiplication of cancer cells, the malignant cells release an
anorexigenic agent, affecting the patient's satiety and resulting in impaired nutrition.

The rapid multiplication of cancer cells is the reason why the patient had a rapid
metabolism, that deprived normal cells of nutrition. To compensate for the lack of nutrition, her
body will increase the breakdown of macronutrients. The increase in macronutrients breakdown
is the reason for the unexplained weight loss. The rapid multiplication of cancer cells also
causes obstruction of the milk ducts, resulting in an inflammatory response. The body will
release chemical mediators and undergo transient vasoconstriction to manage the blood loss.
After a transient vasoconstriction, there will be vasodilation to improve blood flow in nearby
capillaries and tissues, due to vasodilation, plasma fluid leaked into the tissue, causing swelling,
resulted in nerve ending compression, causing the patient to experience severe pain. This is
managed with Paracetamol, Tramadol, and Morphine. This swelling leads to the accumulation of
fluid, cells, cellular debris, and dead lymphocytes, resulting in pus formation. The swelling and
pus caused tissue decay, which resulted in a foul odor. The tumor's size continues to increase,
causing compression of the nearby blood vessels, lymph node compression, and cancer cell
metastasis. The compression of nearby blood vessels causes a decrease in tissue perfusion,
resulting in tissue necrosis, which is why the patient experiences breast discharge. The
compression of the blood vessels causes the obstructed blood vessels to rupture, causing the
patient to bleed.

The tumor has metastasized to other parts of the body as a result of its ongoing growth.
Malignant cells spread to the patient's lymphatic and blood systems. Since it has spread through
the patient's lymphatic and blood systems, it has reached the liver, causing a sudden increase
in the patient SGPT/ ALT, and SGOT/AST, indicating abnormal liver function. As the malignant
cells have reached the liver, it continues to multiply, as a result of the continuous growth, a
new tumor has formed. The formation of a new tumor results in the development of massive
ascites, which then reaches the lungs and causes pleural effusion. The various complications
that occur resulted in the patient's death.
VIII. Laboratory and Diagnostics

Hematology Results
Blood Type: A+

Date Test Result Interpretatio Reference

n Range
09//28/2023 Hemoglobin Mass 99 Low Remarks 115-164 g/L
Hematocrit (Hct) or 0.30 Low Remarks 0.36-0.48
Packed Cell volume
WBC count 11.1 High Remarks 5.0-10.0 x 109 /L
Neutrophils 0.90 High Remarks 0.25-0.70
Lymphocytes 0.10 Low Remarks 0.20-0.40
Platelet Count 133 Low Remarks 150-400 x 109 /L
APTT (Activated 26.5 Normal 24.00-39.00 sec
Partial
Thromboplastin
Time)
09/28/2023 Prothrombin Time
Patient 30.8 High Remarks 10.00-16.00 sec
Control 13.0 Normal 10.00-16.00 sec
% Activity 42.2 Low Remarks 70.00-100%
INR 2.36 High Remarks 0.80-1.10
09/30/2023 Hemoglobin Mass 99 Low Remarks 115-164 g/L
Hematocrit (Hct) or 0.30 Low Remarks 0.36-0.48
Packed Cell Volume
WBC Count 13.7 High Remarks 5.0-10.0 x 109 /L
Neutrophils 0.90 High Remarks 0.25-0.70
Lymphocytes 0.10 Low Remarks 0.20-0.40
Platelet Count 123 Low Remarks 150-400 x 109 /L
Interpretation of the Hematology Results:
Hemoglobin mass and hematocrit values from September 28-30, 2023 shows a
significantly increased value as compared to a normal range, this is primarily due to the usage
of medications to relieve pain. Her blood type is found to be A+. Activated Partial
Thromboplastin Time shows a normal remark. WBC count and Neutrophils level from
September 28-30, 2023 showed a consistent high remark as compared to the reference range,
increased values are associated with increased risk of infection. Lymphocytes and Platelet count
from September 28-30, 2023 presented decreased values as compared to the normal range,
this indicates that the patient has an increased risk in infection. Low platelet and Lymphocytes
are the common side effect of cancer and treatment. Her Prothrombin Time presented an
increased value as compared to the normal range. Prothrombin is a protein made by the liver.
High remarks mean that it takes longer for the blood to clot because the liver is not making the
right amount of blood clotting proteins. This also indicates that there is serious damage in the
liver. Low percent activity slows the blood clotting process, while high INR means that the she
is at risk for bleeding.
Blood Chemistry Results
 Date Test Result Interpretation Reference Range
09/28/2023 Diabetic Profile
HBA1C 5.6% Normal 4.25-6.25%
Fasting Blood 5.54 Normal 3.5-6.2 mmol/L
Sugar (FBS)
Bone/Joint Profile
Blood Urea 4.4 Normal 1.80-7.20 mmol/L
Nitrogen (BUN)
Creatinine 53.0 Low Remarks 62.0-105.00 umol/L
Liver Profile
SGOT/AST 234 High Remarks 0-37 U/L
SGPT/ALT 62.2 High Remarks 0-39 U/L
09/30/2023 Liver Profile
Direct Bilirubin 13 High Remarks 0.0-3.4 umol/l
Total Bilirubin 27 High Remarks 3.41-21.0 umol/L
10/02/2023 Liver Profile
Direct Bilirubin 370.37 High Remarks 0.0-3.4 umol/l
Total Bilirubin 227.15 High Remarks 3.41-21.0 umol/L
Electrolytes
ALK. PHOS 229 Normal 80-306 U/l

Interpretation of Blood Chemistry Report:

The conducted blood chemistry test in September 28, 2023 showed normal remarks of
HBA1C, FBS, and BUN. Her creatinine presented a low remark which is often associated to
having low body mass or weight loss, which are both present with the patient. The SGOT/AST
and SGPT/ALT showed consistent high results as compared to the normal range, this indicates
that there is an abnormal liver function. Direct and total bilirubin has been constantly
presenting high results which may indicates that the liver is not clearing bilirubin properly.
Bilirubin is the yellowish substance found in bile. High levels may cause jaundice. This explains
the yellowish skin discoloration and sclera of the patient.

Ultrasound Results
WHOLE ABDOMEN EXAMINATION
September 29, 2023

The liver is normal in size showing hypoechoic mass seen in both hepatic lobes
measuring 12.9 cm x 8.9 cm in the right and 8.6 x 7.5 cm in the left.
The intrahepatic ducts and common duct are not dilated.

The gallbladder is moderately distended measuring 8.6 cm x 3.9 cm x 3.9 cm

There is intraluminal medium level echo with no posterior acoustic shadowing
Its wall is not thickened.

The pancreas is normal in size and echopattern.

No solid nor cystic mass in the pancreatic area.
The spleen is normal in size and echopattern.
No intrasplenic solid nor fluid mass seen.
The splenic vein is not dilated.

Right Kidney: 10.3 cm x 4.4 cm x 5.5 cm (cortical thickness: 1.2 cm)

Left Kidney: 10.8 cm x 4.1 cm x 4.8 cm (cortical thickness: 1.4 cm)
Both kidneys are normal in size and cortical echogenicity.
No mass, stones nor hydronephrotic changes noted.

The urinary bladder is moderately distended.

No intraluminal echoes seen.
Its wall is not thickened.

The uterus is normal in size showing homogenous echopattern.

The body of the uterus measures 4.4 cm x 2.4 cm x 3.8 cm.
The cervix measures 2.4 cm x 1.2 cm.
The endometrium is echogenic and thin measuring 0.1 cm.
No adnexal mass nor abnormal fluid collection in the posterior cul-de-sac.

There is moderate amount of peritoneal fluid.

Impression:
 Hepatic masses
 Moderately distended gallbladder with bile sludge
 Suggest clinical correlation
 Ascites
 Ultrasonically normal pancreas, spleen, kidneys, and urinary bladder
 Normal sized uterus with thin endometrium
 Suggest clinical correlation
 Negative adnexae
Incidental note: Pleural effusion in the left with approximate volume of 958 cc.

Interpretation of the whole abdomen examination:

Results showed that there are hepatic masses found on both lobes. There is a
moderately distended gallbladder with bile sludge. There is ascites or a moderate amount of
peritoneal fluid accumulated in the peritoneal cavity of the patient. Results showed an
ultrasonically normal pancreas, spleen, kidneys, and urinary bladder. The uterus is in normal
size with thin endometrium. No adnexal mass nor abnormal fluid collection in the posterior cul-
de-sac is found.

BOTH HEMITHORACES
October 3, 2023

Ultrasound of the right hemithorax in correlation with standard chest film shows no free pleural
fluid.

Ultrasound of the left hemithorax in correlation with standard chest film shows free pleural fluid
with approximate volume of 303 cc.
Interpretation of hemithoraces examination:
Ultrasound of the right hemithorax showed a standard chest film with no pleural fluid,
while the left hemithorax showed a standard chest film with pleural fluid with approximate
volume of 303cc. A Chest Tube Thoracostomy is ordered by the physician to drain the fluid
accumulated in the hemithorax, but waver is signed to refuse the treatment.

Interpretation of the Laboratory and Diagnostics:

All laboratory tests that has been carried out and results shows a significantly decreased
hemoglobin mass and hematocrit values, this is primarily due to the usage of medications to
relieve pain. The WBC count and Neutrophil levels from September 28-30, 2023, showed a
significantly increased value as compared to a normal range, while Lymphocytes and Platelet
count showed a significantly decreased value as compared to a normal range. Her Serum
Glutamic-Oxaloacetic Transaminase (SGOT)/ Aspartate Aminotransferase (AST) and Serum
Glutamic-Pyruvic Transaminase (SGPT)/ Alanine Aminotransferase (ALT) showed an increased
value as compared to the normal range, which indicates an abnormal liver function. The total
and direct bilirubin has been constantly presenting high results. Whole abdomen examination
showed hepatic masses and moderately distended gallbladder with bile sludge, moderate
amount of peritoneal fluid, ultrasonically normal pancreas, spleen, kidneys, and urinary bladder,
and a normal sized uterus with thin endometrium. Findings in hemithoraces examination
showed no free pleural fluid in the right hemithorax and free pleural fluid with approximate
volume of 303 cc in the left hemithorax.

IX. Course in the Ward

Date of Admission: September 27, 2023 at 1:45 PM

The patient’s vital signs were checked and recorded as follows: blood pressure of: 90/60
mmHg, temperature of: 36.1 ° C, cardiac rate of: 107 bpm, respiratory rate of: 27 bpm, and
SPO2: 98%. The patient was diagnosed with Breast Cancer with possible Liver Metastasis. After
examination, the physician ordered admission to Internal Medicine (IM) for further evaluation,
including a severe count assessment. Intravenous fluids (IVF) with 1 liter of normal saline
solution (PNSS) every 8 hours were prescribed, along with laboratory tests such as CBC, PC,
BUN/UREA, SGPT/SGOT, UA, and FBS/UBAIC. Medications include Tramadol intravenously, diet
as tolerated, and a non-fasting (NPI) post-meal interval for blood chemistry.
Day 1: September 28, 2023

The attending physician prescribed 1 liter of normal saline solution (PNSS) at 40 cc and
advised continuing the diet. Laboratory requests include WABUTZ, Chest X-ray, Serum, TPAG,
Urinalysis, and Fecalysis. Medications include Ceftriaxone 2g intravenously once daily (OD) with
anti-nausea and stomach protection, and Omeprazole 40 mg intravenously once daily before a
meal (ODAC). Other medications are to be continued.

Day 2: September 29, 2023

 The patient vital signs were checked and recorded as follows: blood pressure of: 90/60
mmHg, temperature of: 36.1°C, cardiac rate: 110 bpm, and SPO2: 95%. The attending
physician ordered intravenous fluids (IVF), advised a diet as tolerated, and recommended a
diagnosis review with repeated tests including CSC, PC, Total cholesterol, Lipid Profile, and
CUAB UTZ. The patient was advised to continue current medications for standby in case of
severe pain. The physician advised the patient to adhere to scheduled chemotherapy, referred
to dietary and nutritional support, vital signs to be checked every 4 hours, and monitoring of
intake and output with proper documentation.

Day 3: September 30, 2023

The attending physician prescribed intravenous fluids (IVF) of normal saline solution
(PNSS) at a rate of 40 cc. The following medications were also ordered: Ceftriaxone, shifted
Omeprazole from intravenous (IV) to capsule (CAP) at 40 mg orally with each meal and at
bedtime, Ranitidine 150 mg capsule every 8 hours, Vitamin B Complex one tablet twice a day,
and Vitamin K 10 mg intravenously as an initial dose, followed by 10 mg every 8 hours for a
total of 3 doses. Reverse isolation is recommended, and caution is advised not to mix with
infectious disease precautions.

Day 4: October 1, 2023

The attending physician prescribed intravenous fluids (IVF) with normal saline solution
(PNSS) at a rate of 1 liter per hour, keeping veins open (KVO). The patient was instructed to
follow a diet as tolerated, with strict aspiration precautions. Additionally, the attending physician
ordered Alkaline Phosphatase (ALP), Bilirubin Profile, and prescribed Morphine twice a day
every 6 hours for severe abdominal pain. Lactulose, 80 cc, was advised every 12 hours orally. A
consent request was made, and the patient was advised to transfer to BMC for ongoing care.
Follow-up with Rifaximin 200 mg was also recommended.

Day 5: October 2, 2023

The patient was examined by the attending physician, and a consent request was made.
The diagnosis includes anxiety, and laboratory tests were recommended. The physician advised
transfer, but the patient remained reluctant. Discussions with a relative regarding prognosis
took place. Follow-up includes continuing the medication Diclofenac at 750 mg every 8 hours.

Day 6: October 3, 2023

The patient was seen and examined by the attending physician, who ordered the
continuation of the present medical management. Consideration of nutritious treatment options
is recommended, with discontinuation once medically stable.

The attending physician diagnosed the need for a chest ultrasound. Pain control
treatment was initiated with the following medications: Morphine 2 mg IV every 8 hours RTC,
Diclofenac 4g IV every 8 hours, and Paracetamol 600g IV every 6 hours. Tramadol, 5g IV every
8 hours, was also administered, and chest ultrasound was continued. The plan includes (B) CTT
insertion once with a repeat chest ultrasound, a referral to an anesthesiologist for pain
management, and the physician advised palliative care.

At 9:23 PM, the attending physician has ordered an increase in Paracetamol to 1g every
6 hours RTC. Additionally, a Tramadol side drip of 400 mg in 500 IV is to run for 24 hours. The
instruction is to hold Morphine for now and resume Morphine as originally ordered.

Day 7: October 4, 2023

The patient was examined by the attending physician and ordered an increase in
Paracetamol to 1g every 6 hours RTC. Additionally, a Tramadol drip of 400 mg in 500 cc was
initiated to run for 24 hours, and the instruction is to hold Morphine for the time being.
Diclofenac is to be continued as originally ordered. Consent for a Nasogastric Tube (NGT) was
also requested.

The physician pronounced the patient’s death at 10:45 PM and initiated post-mortem
care.

Day 8: October 5, 2023

The patient was examined and presented an impaired breathing pattern. She was
received with ongoing IVF of 500 ml normal saline solution (PNSS) with 400 mg of Tramadol,
and a Dopamine drip at 400 cc level. Continuous oxygen inhalation via a face mask was
initiated at 1:51 PM. The patient experienced desaturation with SPO2 dropping to 45%,
respiratory rate of 27 bpm, blood pressure of 95/52 mmHg, and cardiac rate of 119 bpm. The
patient reported unbearable pain, an enlarged abdomen, jaundice, yellowish sclera, and edema
in both lower extremities. Vital signs were monitored and recorded, and the patient was
referred to Dr. Tabanao. Comfort and safety measures were provided, and relatives signed a
waiver refusing resuscitation.
X. Drug Study
XI. Nursing Care Plan
XII. Discharge Plan

This discharge plan will focus on the family and how they would incorporate grieving to
accept the loss of their loved one.

Emotional Aspect:
 Respect and acknowledge the client’s desire for quiet, privacy, and silence.
 Advise the family to reach out to whomever that could help them cope with the situation,
this includes other loved ones and significant others.
 Advise the family members to support each other specially in this trying time.
 Advise the family to grieve on any way they are comfortable and express feelings of anger,
fear and anxiety as part of the grieving process.

Spiritual Aspect:
 Advise the family to pray and have them identify and engage religious activities to promote
grief resolution.