IMMUNO-CANCER Case Study on Invasive Ductal Carcinoma PDF

A Nursing Case Study on INVASIVE DUCTAL CARCINOMA Presented to the San Pedro College of Nursing In Partial Fulfillment of the Requirements in NCM 212 - RLE IMMUNOLOGY/INFLAMMATION/CANCER ROTATION Submitted to: GLORIANNE...

A Nursing Case Study on INVASIVE DUCTAL CARCINOMA Presented to the San Pedro College of Nursing In Partial Fulfillment of the Requirements in NCM 212 - RLE IMMUNOLOGY/INFLAMMATION/CANCER ROTATION Submitted to: GLORIANNE D. RASAY, RN Clinical Instructor Submitted By: JOSIE DONIEKKA R. BONCALES, St. N. ALEX NICOLE M. CORNELIO, St. N. YASMIN SARAH B. MACARANGKAT, St. N. KATHERINE D. REONAL, St. N. LOUIGIE SHANE N. RIVERA, St. N. YESHA ELLAINE S. TEJADA, St. N. BSN 3H Group 1, Subgroup1 October 20, 2024  NURSING CASE STUDY CRITERIA (WRITTEN) Criterion Highest Possible Score Actual Score Introduction and Objectives 5% Data Base (Biographical Data, 10% Clinical Data, Family Health History, Past Health History, History of Present Illness, Developmental tasks) Physical Assessment 5% Definition of Diagnosis 5% Anatomy and Physiology 5% Pathophysiology 10% Medical Management Diagnostic Labs (Actual and 5% Possible) Therapeutics and Drug Studies 5% Nursing Management Nursing Theory 5% Nursing Care Plans 15% Review of Related Literature 5% Discharge Planning 5% Prognosis 5% Promptness, Format, References 15% TOTAL: 1  TABLE OF CONTENTS I. INTRODUCTION 4 II. OBJECTIVES 5 A. GENERAL OBJECTIVES 5 B. SPECIFIC OBJECTIVES 5 III. DATA BASE 6 A. BIOGRAPHICAL DATA 6 B. CLINICAL DATA 7 C. FAMILY HEALTH HISTORY 7 D. PAST HEALTH HISTORY 8 E. HISTORY OF PRESENT ILLNESS 8 F. DEVELOPMENTAL TASKS 9 II. PHYSICAL ASSESSMENT 13 PHYSICAL ASSESSMENT 1 13 a. GENERAL SURVEY 13 b. SKIN AND NAILS 14 c. HEAD AND HAIR 14 d. EYES AND VISUAL ACUITY 14 e. EARS AND HEARING 15 f. NOSE AND SINUSES 15 g. MOUTH AND OROPHARYNX 16 h. NECK 16 PHYSICAL ASSESSMENT 2 17 a. THORAX AND LUNGS 17 b. HEART, CENTRAL VESSELS, AND PERIPHERAL VASCULAR SYSTEM 17 c. BREAST 18 d. ABDOMEN 18 e. GENITOURINARY 18 PHYSICAL ASSESSMENT 3 18 2  a. MUSCULOSKELETAL 18 b. NEUROLOGIC 19 i. CRANIAL NERVE ASSESSMENT 19 ii. GLASGOW COMA SCALE 21 III. DEFINITION OF DIAGNOSIS 22 IV. ANATOMY AND PHYSIOLOGY 23 V. PATHOPHYSIOLOGY 30 A. ETIOLOGY 30 B. SYMPTOMATOLOGY 37 C. SCHEMATIC TRACING 40 D. NARRATIVE 43 VI. MEDICAL MANAGEMENT 46 A. DIAGNOSTIC EXAMS AND LABORATORY TESTS 46 a. ACTUAL TESTS DONE 46 b. POSSIBLE TEST 88 B. SURGICAL PROCEDURES 93 a. ACTUAL SURGICAL PROCEDURE DONE 93 b. POSSIBLE SURGICAL PROCEDURES TO BE DONE 95 C. THERAPEUTICS AND DRUG STUDIES 101 a. MEDICAL ORDERS 101 b. DRUG STUDIES 109 DRUG STUDY 1 - OMEPRAZOLE 109 DRUG STUDY 2 - LOSARTAN 111 DRUG STUDY 3 - MIDAZOLAM 115 DRUG STUDY 4 - AMLODIPINE 118 DRUG STUDY 5 - ROSUVASTATIN 122 DRUG STUDY 6 - DEXKETOPROFEN TROMETAMOL 126 DRUG STUDY 7 - MEFENAX 129 DRUG STUDY 8 - PARACETAMOL 132 3  DRUG STUDY 9 - TRAMAL 135 DRUG STUDY 10 - NUBAIN 140 DRUG STUDY 11 - SULTAMICILLIN 143 IX. NURSING MANAGEMENT 145 a. NURSING THEORY 145 b. NURSING CARE PLANS 148 NURSING CARE PLAN 1 156 NURSING CARE PLAN 2 160 NURSING CARE PLAN 3 164 NURSING CARE PLAN 4 169 NURSING CARE PLAN 5 173 c. REVIEW OF RELATED LITERATURE 178 d. DISCHARGE PLANNING 179 X. PROGNOSIS 185 XI. REFERENCES 186 XI. APPENDICES 192 4 I. INTRODUCTION The current rotation Immunology/Inflammation/Cancer ward provides an in-depth exploration of the interplay between the immune system and cancer. Studies of the mechanisms of immune response, inflammation, and how these processes contribute to tumor development and progression. The rotation includes clinical exposure, laboratory techniques, and discussions on current research and therapies, making us understand the complexities of treating cancer through immunological approaches. Invasive ductal carcinoma (IDC) is the most common type of breast cancer, accounting for approximately 80% of all breast cancer cases. It originates in the milk ducts and invades surrounding breast tissue, which can lead to metastasis. IDC typically presents as a lump or thickening in the breast, and it may be detected through mammography or clinical examination. Risk factors include age, family history, genetic mutations (like BRCA1 and BRCA2), and lifestyle factors (Wright, 2023). Invasive ductal carcinoma (IDC) is the most common form of breast cancer, accounting for approximately 80–85% of all breast cancer cases worldwide. Globally, there were an estimated 2.3 million new cases of breast cancer in 2020, with IDC representing the majority of these cases (World Health Organization, 2021). In the Philippines, breast cancer is the leading cancer among women, with around 27,000 new cases diagnosed annually. IDC constitutes over 80% of these cases, resulting in approximately 21,600 cases of IDC per year. (Philippine Cancer Society, 2023). In the Davao Region, SPMC records show the number of patients diagnosed with breast cancer ranges from an average of 184 patients from 2019 to 2021, to 404 in 2022, Dr. Kenny Jun Demegillo, SPMC medical oncology section training officer, said (Ocampo, 2023). Following national trends, IDC likely accounts for 80% of these cases. Our patient, A.B., a 56-year-old Filipino housewife from Davao City, presented with a final diagnosis of Invasive Ductal Carcinoma, Stage IIA (T2N0M0). A.B. is an interesting case due to the nature of her breast mass, which was discovered to be hard and lobulated with fine calcifications, as revealed by sonomammography. A core needle biopsy confirmed a poorly differentiated invasive ductal carcinoma, with immunohistochemistry showing ER/PR positivity and HER2 negativity, consistent with the luminal A subtype. She was admitted to San Pedro Hospital for a scheduled surgery following these findings. 5  The integration of microRNA (miRNA) signatures and proteomics-based biomarkers into the treatment of invasive ductal carcinoma (IDC) affects nursing practice, education, and research. Nurses must have information about molecular profiling and biomarkers to provide personalized patient care, educate patients about a condition in specific terms, and ensure better outcomes for patients in the clinics (Verma et al., 2024; Neagu et al., 2023). In addition, technology-based tools like Convolutional Neural Networks (CNNs) prepare nurses to effectively employ advanced technologies in screening and post-diagnostic care. Therefore, they are better prepared in improving patient outcomes and encouraging trust in the newer diagnostic methods (Dequit & Fatema Nafa, 2024). These developments exemplify that nursing is at the forefront of the use of research and technology to build upon the advancement of patient care, enriching higher educational programs, and in supporting continuous research in oncology. II. OBJECTIVES A. GENERAL OBJECTIVES Within the 4 weeks of Immunology, Inflammation, and Cancer Ward, the students of BSN 3H - Group 1, Subgroup 1 will be able to understand the implications of the condition on immunology/inflammation/cancer, refine immunology/inflammation/cancer assessment skills, and enhance their critical thinking skills in the clinical setting. B. SPECIFIC OBJECTIVES At the end of the Immunology and Cancer Ward Nursing Rotation, the BSN 3H Group 1- Subgroup 1 will be able to: a. Define the rotation and provide a comprehensive introduction and concise overview on Invasive Ductal Carcinoma and incorporate findings and statistics from international, national, and local scale; b. create a specific, measurable, attainable, realistic, and time-bounded (SMART) general and specific objectives; c. organize the patient’s database such as biographical and clinical data, family history, past and present history, and developmental task; d. present the performed physical and neurological examination; e. define the definition of diagnosis; f. determine the affected organs of the condition in the anatomy and physiology; 6  g. identify the etiology such as the predisposing and precipitating factors related to the condition; h. trace the pathophysiology of Invasive Ductal Carcinoma through schematic diagram; i. obtain the medical orders such as diagnostic exams and laboratory tests, ordered medications, and monitoring orders through a comprehensive review of the medical records. j. identify nursing theories that are applicable to the client’s case; k. formulate five (5) nursing care plans based on the top priority problem; l. construct a discharge plan using the METHOD format for the client’s continuity of care; m. determine the possible prognosis of the patient; and n. Cite the references utilized in the case study following APA format. III. DATA BASE A. BIOGRAPHICAL DATA a. Name: A. B b. Birthdate: October 10,1968 c. Age: 56 d. Address: Brgy. Villarica, Babak, Igacos, Island Garden City of Samal e. Educational Attainment: College Graduate f. Occupation: Housewife g. Nationality: Filipino h. Religion: Roman Catholic i. Civil Status: Married j. Name of Spouse: B.B k. Educational Attainment: High School l. Occupation: Vendor m. Name of Mother: L.B. n. Name of Father: A. B. 7  B. CLINICAL DATA a. Hospital of Confinement: San Pedro Hospital b. Ward: San Lorenzo Ward c. Room and Bed No: 308 - (4) d. Chief Complaint: Breast Mass, Right e. Attending Physician: Dr. Rongo f. Date of Admission: October 14, 2024 g. Admitting Diagnosis: Invasive Ductal Carcinoma, Poorly DIfferentiated h. Final Diagnosis: Invasive Ductal Carcinoma Right Breast (Stage IIA) T2N0M0 C. FAMILY HEALTH HISTORY Patient A.B.'s genogram reveals that her paternal grandparents have passed away, while her maternal grandmother is the only one lost on that side; the cause of death for the grandparents is unknown. However, it is noted that her maternal grandmother was bitten by a snake. A.B. does not recall any details about her mother's siblings, but she mentions a cousin who has been diagnosed with breast cancer. On the paternal side, A.B. also cannot recall her father's siblings, although she was close to her aunt, who is suffering from dementia. Tragically, A.B.'s father passed away due to a gunshot wound. 8  A.B. is the fifth child among her 11 siblings. She notes that one of her sisters has also been diagnosed with breast cancer, but she cannot recall the health conditions of her other siblings. D. PAST HEALTH HISTORY Patient A.B. has a medical history that includes a urinary tract infection (UTI) and hypertension. She is currently on a maintenance regimen for her hypertension, which includes Losartan 100 mg (1 tablet once daily), Amlodipine 5 mg (1 tablet once daily), and Rosuvastatin 10 mg (1 tablet once daily). At the age of 20, she experienced tonsillitis, and at age 40, she contracted chickenpox. Patient A.B. is fully vaccinated against all recommended immunizations, including BCG, Hepatitis B, DPT (Diphtheria, Pertussis, Tetanus), OPV (Oral Polio Vaccine), Measles, COVID-19, and Pneumococcal disease. She has no known allergies and does not smoke or consume alcohol. E. HISTORY OF PRESENT ILLNESS Five months before admission, the patient noticed the onset of a mass in her right breast. It was nontender, hard, and firm. Since it did not affect her daily activities, no medications were taken, and there were no associated symptoms. The patient did not seek medical consultation during this period and tolerated the condition. Two months prior to admission, with no change in symptoms, the patient sought consultation with her attending physician, who recommended bilateral sonomammography and a biopsy. Sonomammography revealed a 2.4 cm x 2.2 cm lobulated, dense mass with fine calcifications in the lower inner quadrant of the right breast. A core needle biopsy confirmed invasive ductal carcinoma, poorly differentiated. Immunohistochemistry showed ER/PR positivity, HER2-negative, consistent with luminal A subtype. The patient was advised to undergo surgery, and on the day of admission, she was scheduled for the procedure. The patient reported no weight loss, fever, cough, abdominal pain, or diarrhea leading up to the admission. 9 F. DEVELOPMENTAL TASKS ERIK ERIKSON’S STAGES OF DEVELOPMENT Erik Erikson's stages of development serve the purpose of understanding and explaining the psychosocial development of individuals across their lifespan. Each stage represents a specific developmental challenge or conflict that individuals must navigate to progress successfully to the next stage. In the case of our patient, she belongs to Erik Erikson's 7th stage of psychosocial development, which is "Generativity vs. Stagnation" and typically occurs in individuals aged 40-65 years old. During this stage, middle-aged adults strive to create or nurture things that will outlast them, often by parenting children or fostering positive changes that benefit others. Contributing to society and doing things to promote future generations. (Cherry, 2024) ACTIVITY GENERATIVITY VS. JUSTIFICATION STAGNATION Generativity vs. Generativity This patient has undeniably Stagnation achieved Erikson's developmental stage of Generativity. According to her, she focuses her years at this point on providing guidance to her children who are entering and on early adulthood. She mentions that she gives no regard to losing a breast because she thinks her prime has already passed and her focus right now goes towards her children. This demonstrates her ability to look beyond herself and contribute positively to future generations, fostering a sense of continuity and purpose. Her ability to move forward with her life and 10  set her personal goal to give back to society by raising her children the best she can demonstrates a generativity approach. ROBERT HAVIGHURST'S DEVELOPMENTAL TASK THEORY Havinghurst's developmental task theory focuses on the key tasks and challenges individuals face at different stages of life, emphasizing the importance of successfully mastering these tasks for healthy development. According to Havinghurst, each life stage presents specific social, emotional, and cognitive tasks that individuals must address to progress successfully. In the case of our patient who is in the stage of later maturity, Havinghurst's developmental task theory helps us understand the challenges and goals she may encounter during this phase of life. The theory outlines key tasks individuals should achieve at various life stages. At age 56, individuals are typically navigating the stage of middle adulthood, which is characterized by several significant developmental tasks. Stage: Middle Adulthood (30-60 years old) DEVELOPMENTAL TASK ACHIEVED OR NOT JUSTIFICATION ACHIEVED Achieving Adult Civic and ACHIEVED Patient has achieved civic and Social Responsibility social responsibility as she continues to become an active voter and involve in fulfilling obligations such as educating her children about the economical problems present today as she mentioned how there are a lot of political controversies going around. She also provide initiative in giving produce on people around their community especially if their harvest is good. 11 Establishing and Maintaining ACHIEVED The main source of income for an Economic Standard of years of their family has Living always been their fruit shake stand in Samal. Patients have successfully kept their life comfortable enough to sustain their needs and have established a stable life from it. For heavy finances such as hospital bills, she asks for additional assistance from her siblings. Assisting Teenage Children ACHIEVED Patients dedicate her time and focus on helping her children as they enter and start adulthood. She has mentioned her children are quite independent but she provides as much assistance as she can to fulfill her role as a mother. Developing Adult ACHIEVED Patient mentioned that now Leisure-time Activities that she has become a housewife, she usually spends her time watching reels or any sort of entertainment on the internet that she can find. If she’s not on her phone she would engage with her neighbors from time to time. Relating to One’s Spouse as NOT ACHIEVED She has mentioned that her a Person husband being the quiet and distant type, usually just playing basketball and cycling, decisions and problems in the family are usually left for her to handle. She mentioned “mawadan nasad kog gana gani; di magtingganay” referring to how communications between them are uncoordinated. Accepting Physiological ACHIEVED Our patient has successfully changes of Middle Age adjusted to decreasing strength and health by making practical modifications to her 12  daily activities. She specifically mentioned that she does not engage in heavy tasks anymore as much as she can because she sometimes experiences shoulder soreness and has a hard time bending when carrying heavy objects which is why she has left her work as a vendor giving the full responsibility to her husband. Additionally, her proactive approach to seeking medical assistance when needed demonstrates her awareness and responsibility toward maintaining her health and well-being. She follows her drug maintenance to control hypertension and is conscious of her diet to avoid developing further problems as she gets older. Adjusting to Aging Parents ACHIEVED Patient’s father is deceased while her mother is 82-years old and living. She stays together with her siblings and she provides assistance to them emotionally, physically, and financially. She has acknowledged that her mother is at an age where she has to be taken care of at times that is why she and her siblings provide them as much support as they can. 13 II. PHYSICAL ASSESSMENT PHYSICAL ASSESSMENT 1 a. GENERAL SURVEY A physical assessment was conducted on patient A.B., a 56-year-old Filipino female, on October 16, 2024, Wednesday, at 9:30 a.m. She was diagnosed with Invasive Ductal Carcinoma. The patient was observed to have a mesomorph body type, weighing 53 kg and measuring 148 cm in height. Her body mass index is 24.2 kg/m², which falls within the normal category. During the assessment, the patient was wearing a hospital gown and sitting comfortably. Her vital signs were recorded as follows: temperature 36.4°C, heart rate 70 bpm, respiratory rate 18 cpm, pulse rate 69 bpm, blood pressure 120/80 mmHg, and oxygen saturation of 97%. The patient has a Jackson-Pratt (JP) drain on the right side, is receiving intravenous fluids of D5LR at a rate of 120 cc/hr, without supplemental oxygen, and has bathroom privileges. She exhibited normal posture and appeared alert, awake, and oriented, demonstrating an appropriate verbal response when answering questions. Patient A.B. was well-groomed, indicating good self-care. It was determined that she may go home with JP drain during endorsement. VITAL SIGNS NORMAL RESULTS Temperature 36.5 - 37.5 °C 36.4 °C Pulse Rate 60-100 bpm 69 bpm Respiratory Rate 16-20 cpm 18 cpm Cardiac Rate 60-100 bpm 70 bpm Blood Pressure 110/70 - 120/80 120/80 mmHg mmHg 14 b. SKIN AND NAILS Upon inspection, the client’s skin was noted to be uniform in color, with a smooth texture to the touch. Skin turgor was assessed and quickly returned to its original position when pinched, indicating proper hydration and elasticity including the collarbone and the chest skin turgor. The skin feels warm and dry, with no signs of excessive moisture. There are no lesions, edema, or ulcerations, indicating intact and healthy skin. The client's nails are well-trimmed, clean, and pink in color, with no signs of deformity. They are free of ridges and pitting, with a normal thickness. Capillary refill time was less than 2 seconds, reflecting good blood flow. c. HEAD AND HAIR During the examination, it was observed that the patient’s head displayed normocephalic configuration. The hair is evenly distributed, with white hairs predominantly in the front area, and the scalp is clean without any presence of dandruff, lice, lacerations, and tenderness or swelling noted upon assessment. The client has symmetrical facial features, palpebral fissures are equal, and jaw strength is normal. d. EYES AND VISUAL ACUITY Upon examination of the eyes, it was noted that the patient displayed symmetrical movement and hair distribution of the eyebrows. No scaling or sparse areas were observed. Eyelashes were outwardly curled, and eyelids exhibited symmetry without visible skin breaks. There was no indication of lacrimal duct irritation, discomfort, or edema. The conjunctiva appeared pink, while the cornea and lens exhibited smoothness and a shiny appearance. There was no evidence of edema but discoloration was noted as the periorbital region appears darker but not sunken. Sclera was normal and healthy, showing no signs of jaundice. In 15  terms of functional vision, the patient demonstrated the ability to count fingers, see hand movements and convergence is coordinated. A normal visual field indicates that the patient's peripheral vision is intact by assessing with the six cardinal directions: up/right, right, down/right, down/left, left, and up/left and noted that there are no significant abnormalities affecting her field of vision. The patient wears reading glasses due to difficulty in reading small print. e. EARS AND HEARING During the examination of ears and hearing, the pinna is aligned with the outer canthus of the eye, which were normoset and symmetrical with no tenderness when palpated. Both ears have normal hearing acuity. The test for hearing is normal in both ears, which is proven using the whisper word test, in which the patient was sitting on the bed and the examiners stood an arm’s length away behind the patient whispering the following: "2.5.6, 1.3.4, and 9.A.3.", approximately 2 feet away from the patient. Moreover, the Weber test and Rinne test were also assessed by the examiner using a tuning fork. In the Rinne test, the results in both ears are normal through air conduction, as the patient could hear the tuning fork’s vibration when held next to the ear, without needing to place it behind the ear on the mastoid process, where bone conduction occurs. However, during the Weber test, when the vibrating tuning fork was placed on the center of the patient's head, she could not hear anything in either ear or identify whether the sound was louder in the left, right, or center. f. NOSE AND SINUSES During the nose examination, the nasolabial fold appears symmetrical, and the nasal septum is centered. The nasal mucosa has a pinkish hue, with no visible lesions, no redness, and swelling, and no discharges noted. Both nostrils are open, and 16  there is no tenderness upon palpation of the maxillary, frontal, and ethmoid sinuses. g. MOUTH AND OROPHARYNX During the oral examination, the lips appeared symmetrical, and the inner lining of the mouth was pink and moist, with no visible lesions. The tongue was positioned midline, with minimal white spots observed. The palate, mucosa, and gums were also pinkish in color. The labial and lingual frenulum were midline and smooth, allowing for adequate movement when the tongue was raised and the mouth opened. The gag reflex was positive, as evidenced while the patient was drinking water. The uvula was positioned midline. Additionally, several teeth were missing, including the right upper first molar, second premolar, left upper second premolar, second molar, and lower right first and second molars. Dental caries were noted on the right upper second molar, left upper first molar, and cavities were present in the left lower second premolar and first molar. She is using dentures for her upper teeth. h. NECK During the assessment of the neck, the examiner noted that the trachea was positioned centrally and aligned with the midline. Upon examination, neither the lymph nodes nor the thyroid were palpable. The thyroid gland could not be felt, indicating normal size and texture. The neck's range of motion was normal, showing smooth movement without pain or discomfort. There was no jugular vein distention noted and the patient demonstrated normal neck muscle strength by actively moving against resistance when the hand was placed against both the left and right cheeks. 17 PHYSICAL ASSESSMENT 2 a. THORAX AND LUNGS Respiratory Excursion full and symmetric or equal on chest expansion;. Spinal alignment is symmetrical, no tenderness and bulges. The patient's breathing pattern is effortless, no use of accessory muscles. The chest skin turgor on the left side of the chest and below the collarbone is good, the chest was checked by asking the patient to pinch a small portion of the skin on her chest. The patient’s respiratory excursion was assessed by placing the palms at the hemithorax and asking the patient to do a deep breath and it is noted as symmetrical. Tactile fremitus was assessed carefully and it is evaulated as it is diminished on the right side of her chest due to her recent mastectomy, while the left side shows normal vibrations. The patient's percussion notes are resonant on both the left and right sides, but the right side is slightly diminished compared to the left, likely due to her recent surgery. Furthermore, breath sounds were bronchial, with no signs of wheezes, crackles, or friction rub observed. b. HEART, CENTRAL VESSELS, AND PERIPHERAL VASCULAR SYSTEM The precordium of the patient appeared normodynamic, as there was no heave, thrill, or tenderness observed and noted throughout the assessment. There were also no murmuring sounds heard during auscultation. The patient’s aortic, tricuspid, pulmonic, and apical heart sounds were distinct. The patient’s temporal, carotid, apical, brachial, radial, popliteal,dorsalis pedis, and posterior tibia pulses were strong. The calf tenderness was negative indicating the absence of pain and no signs of deep vein thrombosis 18  c. BREAST The patient's left breast is uneven but shows no masses. The skin is clear of redness and is non-tender, with a normal areola that points outward, brown in color. Due to her diagnostic findings, the patient has no right breast. A Jackson-Pratt (JP) drain is placed at the incision site on the right side. Consent was obtained before discussing the assessment, and the patient performed a self-assessment for her own privacy and comfort. d. ABDOMEN Further assessment of the abdomen could not be performed due to the patient's refusal. e. GENITOURINARY We encouraged the patient to conduct a self-assessment, but she only reported on her pubic hair, describing it as scanty. She began her menstrual periods at age 13 and experienced menopause by age 53. PHYSICAL ASSESSMENT 3 a. MUSCULOSKELETAL The patient’s muscles are in equal sizes and no disproportionate abnormalities were noted. Evaluation of muscle strength, comparing both sides, including the sternocleidomastoid, trapezius, biceps, triceps, finger/wrist, hip (raising), hip (abduction/adduction), hamstring, quadriceps, and ankles/feet, indicates a grade of 5, suggesting active movement against full resistance. Additionally, both bones and joints display symmetrical strength. 19  SCORE INTERPRETATION 0 No muscular contraction. 1 A barely detectable trace of contraction. 2 Active movement with gravity eliminated. 3 Active movement against gravity. 4 Active movement against some resistance. 5 Active movement against full resistance. b. NEUROLOGIC i. CRANIAL NERVE ASSESSMENT CRANIAL NAME FUNCTION RESULTS NERVE I Olfactory Sensory During the assessment, the patient Nerve was asked to identify two distinct scents: alcohol and perfume, while her eyes were closed. The patient successfully recognized both. II Optic Nerve Vision For this cranial nerve assessment, the Snellen Chart was not used. Instead, the examiner showed numbers using her fingers and wrote the words 'PENCIL,' 'BLANKET,' and 'THREE' in the ward notebook while using her reading glasses, approximately 2 feet away from the patient. III Oculomotor Eye movement The patient’s pupils were round and responsive to light, constricting Nerve (upward, when exposed to it and dilating in downward, absence of light. inward) and pupil reaction IV Trochlear Eye movement Both of the patient’s eyes exhibited smooth tracking of the penlight, Nerve indicating proper function during the 20  assessment of the six extraocular movements. V Trigeminal Facial sensation The patient was able to eat. Her jaw movement was assessed by asking Nerve and mastication him to open and close his mouth and move his jaw side to side. The patient could feel blunt objects, as demonstrated by tracing a penlight on her arm. No abnormalities were detected. VI Abducens Lateral eye During the assessment, the patient demonstrated the ability to move Nerve movement both eyes laterally by tracking the penlight and pen. VII Facial Facial The patient showed various facial movements, including raising the Movement And eyebrows, smiling, puffing out the expression cheeks, and forcefully closing the eyes. Each of these movements was closely observed to assess muscle function and symmetry, checking for any abnormalities or weakness in facial expression and strength. VIII Vestibuloco Hearing and The patient's hearing was assessed and found to be normal in both ears chlear balance using the whisper word test, where Nerve the examiner stood about two feet behind the patient and whispered specific numbers and letters. Additionally, the Weber and Rinne tests were performed with a tuning fork. The Rinne test results were normal, indicating good air conduction, as the patient could hear the tuning fork's vibrations held next to the ear without needing it placed behind the ear. However, during the Weber test, the patient was unable to hear the sound when the vibrating tuning fork was placed at the center of her head, nor could she determine if the sound was louder in one ear or the other. 21  IX Glossophar Swallowing, The patient exhibited a gag reflex when the posterior pharyngeal wall yngeal sense of taste was stimulated with a tongue Nerve depressor. X Vagus Talking and The patient's speech sound was Nerve clear with no hoarseness noted. swallowing She was able to swallow when she drank a cup of water during assessment. XI Accessory Movement of The patient demonstrated strength Nerve by shrugging her shoulders and sternocleidomas turning her head against resistance. toid and trapezius muscles XII Hypoglossal Tongue The patient was able to move her Nerve tongue from side to side and up on movement the hard palate when asked. ii. GLASGOW COMA SCALE GLASGOW COMA SCALE Behavior Response Normal Score Score Eye Spontaneously 4 4 Opening Response Verbal Oriented to time, 5 5 Response person & place Motor Obeys Command 6 6 Response Total: 15/15 Total: 15/15 During the neurological assessment, the patient demonstrated spontaneous eye-opening without any external stimulation, resulting in a score of four. She was able to respond coherently and appropriately to questions regarding her name, location, and the time, earning a score of five. 22  Furthermore, she successfully followed simple commands such as "squeeze my hand" and "raise your arm," which gave her a score of six for best motor response. Overall, the patient achieved a Glasgow Coma Scale (GCS) score of 15, indicating that she is fully awake, responsive, and has no cognitive or memory issues. She was also able to recall all her siblings' birth dates. While her attention span appeared focused, it became divided during the assessment as the assessment went along, she was using her phone to contact her husband. III. DEFINITION OF DIAGNOSIS According to Wright (2023), invasive ductal carcinoma stems from the ducts of the breast. These ducts are known passageways through which milk from the milk glands or lobules flows to the nipple. It is a cancer (carcinoma) that results from abnormal cells that grew in the lining of the milk ducts and changed to invade the breast tissue beyond the walls of the duct. Once this happens, the cancerous cells become capable of moving out of the main part of the body. They can invade the lymph nodes or the blood and go ahead to other organs in the body. This means they cause what is termed as metastatic breast cancer. In contrast, Stein & Luebbers (2019) explains that carcinoma of the ducts of the breast starts in the epithelial cells lining the milk ducts. This type of malignancy is characterized by abnormal cell growth, divided into non-invasive forms, which include ductal carcinoma in situ (DCIS), where the cancerous cells remain confined to the ducts, and invasive ductal carcinoma, where the cancer invades surrounding tissue with the risk of metastasizing to other parts of the body. Early detection and proper treatment are therefore paramount for a good prognosis. On the other hand, Mariotti (2018) defines invasive ductal carcinoma (IDC) as a type of breast cancer that originates in the milk ducts itself and invades the surrounding breast tissue. This cancer is characterized by the infiltration of abnormal cells beyond the ductal walls, which is why it is also referred to as infiltrating ductal carcinoma. As these abnormal cells multiply, they eventually break through the walls of the ducts into the surrounding stroma, composed of fatty and fibrous connective tissue. This invasive behavior significantly heightens the risk of metastasis, allowing cancer cells to spread to nearby lymph nodes and other organs. 23  In summary, Wright (2023) describes invasive ductal carcinoma (IDC) as cancer originating in the milk ducts itself that invades surrounding tissue and can metastasize, while Stein and Luebbers (2019) focused its origin from the epithelial cells while distinguishing IDC from non-invasive forms like ductal carcinoma in situ (DCIS) and emphasize the importance of early detection, and Mariotti (2018) highlights IDC’s aggressive infiltration beyond the ductal walls into the stroma, increasing the risk of spreading to other organs. IV. ANATOMY AND PHYSIOLOGY BREAST (REPRODUCTIVE SYSTEM) The breast is one of the glandular organs whose main function is to produce and secrete milk during periods of lactation, and it plays an essential role in the female reproductive system. This organ is mainly functioning to feed infants through breast milk, which contains important nutrients, antibodies, and certain hormones, thereby aiding in growth and immune protection. Thirdly, the breast affects sexual health, and breast tissue is also sensitive to fluctuations in hormones in a woman's life, as a result of menstruation, pregnancy, or menopause. The breast is considered part of the endocrine system as it also entails exposure to hormones that include estrogen and progesterone, controlling growth and its functioning. 24  Moreover, the breast is part of the integumentary system, which comprises the skin as well as its derived appendages such as hair and nails and glands. The skin covering the breast provides the functions of protection, sensation, as well as thermoregulation, whereas the glandular tissue under the skin is responsible for the production and secretion of milk during lactation. In this way, the breast presents both reproductive and integumentary functions, forming a very complex anatomy and physiology. The anatomy of the breast is complex and specifically designed to consist of an aggregation of tissue designed essentially for the production and delivery of milk. Formed from lobes, lobules, ducts, the nipple, areola, stroma, and an extensive blood and lymphatic supply, each component has its specific role within both reproductive as well as overall breast health. Lobes and Lobules The breast contains 15 to 20 lobes, the units responsible for milk production. Smaller structures, called lobules, exist within each lobe and contain the alveoli-thin-walled, sac-like glands within which the milk is synthesized and stored during lactation. Lobes and lobules are arranged in a radial fashion from the nipple and are interconnected by a network of ducts. It is the structure that allows milk movement from lobules to the nipple of a breast during breastfeeding. 25 Ducts The milk ducts represent thin tubes that connect the lobules to the nipple. They act as conduits along which milk moves and is transported to the nipple when breastfeeding occurs. The ducts are lined with epithelial cells, with a possibility for those changes to give rise to conditions like ductal carcinoma. From the lobules, they branch and merge as they approach the surface to form thicker ducts. This ductal system is very essential to proper performance of the breast during lactation. Nipple and Areolar The nipple is the protruding body in the center of the breast, whereby milk is squeezed out at the time of lactation during breastfeeding. This area around the nipple is the areola, which is actually an annular pigmented region of skin, with small glands-Montgomery glands filled with the secretion that lubricates the nipple during breastfeeding. The color and texture of the areola differ between 26 different persons and according to pregnancy or lactation. The nipple and areola are closely related elements in breastfeeding, both critical because they are highly sensitive touch-sensitive organs, which could stimulate the ejection reflex of milk. Stroma The stroma is the supporting tissue of the breast, which provides an envelope for the lobes, lobules, and ducts. It consists mainly of connective tissue and fatty tissue with blood vessels. It can also provide structural support and nourishment to all components within the breast. The proportion of this stroma may be different and may change across age, hormonal changes, and body composition, thus affecting the overall shape and density of the breast. The stroma also has an important role in the reaction of the breast tissue to hormonal signals during the menstrual cycle and pregnancy. Blood Supply and Lymphatic System Major contributors to the arterial supply of the blood to the breast are the inner thoracic artery, lateral thoracic artery, and the thoracoacromial artery. Such arteries give the blood vessel adequate oxygen and nutrients supply. The breast is made up of a network of lymphatic vessels and nodes conducting lymph fluid for immune functions and regulation of fluid balance. Axillary lymph nodes that are located in the armpit region are especially important because cancer 27  commonly spreads to that area from the breast, and lymphatic drainage to these nodes is important for maintaining the health of the breast and for finding pathological changes. LYMPHATIC SYSTEM The lymphatic system is the immunity and circulatory system that consists of a chain of vessels, lymph nodes, and lymphoid tissues working together to regulate the fluid balance, filter harmful substances, and respond to the immune system. The system includes lymphatic vessels that carry lymph, colorless fluid composed of leukocytes and waste products, beginning as tiny capillaries, absorbing excess interstitial fluid, and returning it to the blood flow. Lymph nodes are small bean-shaped bodies, scattered along these vessels, which filter out lymph and trap pathogens, housing immune cells like lymphocytes and macrophages that help to destroy the invaders. The spleen, thymus, and tonsils make up the main lymphoid organs. These tissues develop further immunity in a human body. Lymphatics are significantly essential for the health of the breast; they play an essential part in the lymphatic drainage. 28  Lymphatic vessels are well-represented in the tissue of the breast tissue that channels lymph fluid into axillary lymph nodes in the armpit, among others. This pathway of drainage is important in breast cancer in that the cells can invade lymphatic vessels and secondarily metastasize through the lymph nodes; often, it may be the first site for metastasis. The status of these axillary lymph nodes becomes a very important factor in the staging of breast cancer and in the treatment options. Damage to the lymphatic vessels during surgery or radiation therapy can cause swelling in the arm or breast from fluid buildup known as lymphedema. In summary, the lymph system plays a more significant role in breast health and the implications of breast cancer. INTEGUMENTARY SYSTEM The integumentary system consists of the skin, hair, nails, and several glands and is the body's largest organ system. It has four primary functions: protection, regulation, sensation, and synthesis. The skin is a barrier to the subjacent tissues in an attempt to prevent harmful agents and physical damage. It maintains a balance and temperature with the fluid of the body. The three main layers making up the integumentary system are the epidermis, dermis, and hypodermis. The outermost layer of the skin is the epidermis, formed by stratified squamous epithelial tissue and consisting of keratinocytes responsible for keratin 29 production and melanocytes responsible for melanin production for the coloration of the skin. Under the epidermis, there is an almost thicker layer formed of connective tissue called the dermis. This layer hosts blood vessels, nerve endings, hair follicles, and glands, such as sebaceous and sweat glands. The dermis is stronger, elastic, and a nourishment layer which contains sensory receptors to register pressure, pain, and temperature. Below the dermis is the hypodermis, or subcutaneous layer, which consists of loose connective tissue and fat-a subdermal insulator, shock absorber, and anchor point for the skin. The integumentary system serves several important physiological roles. Its main function is to provide protection as the first line of defense in any environmental attacks from pathogens, chemicals, and mechanical injuries. The skin is concerned with thermoregulation, ensuring that a stable body temperature is maintained, since it produces sweat, and the diameter of blood vessels is altered to assist in this process. Another role is sensation, which occurs in the many sensory receptors of the skin and involves touch, pressure, pain, and temperatures, allowing the body to respond appropriately to changes in the surroundings. Finally, the integumentary system manufactures vitamin D when exposed to sun light, which absorbs calcium and hence promotes bone formation. The system also excretes in sweat, by disposing waste products from the body and maintaining its own temperature. Hair and nails add another layer of protection and sensory functions. In summary, the integumentary system is very essential in maintaining homeostasis and protection of the body while also interacting with the outside world. 30 V. PATHOPHYSIOLOGY A. ETIOLOGY PREDISPOSING FACTORS FACTOR RATIONALE REMARKS JUSTIFICATION Age The risk of developing PRESENT Patient is 56 years ductal carcinoma old which falls at increases much with the age group advancing ages, especially vulnerable in after age 50. Most breast developing cancer cancer is diagnosed in because of women above age 55 thus cumulative implicating the critical role exposure to aging plays in breast carcinogens and cancer risk. natural decline of the body's repair ability. Gene The two important genes PRESENT In the case of our that assist in fixing DNA or patient, this type of cell growth are BRCA1, cancer is present located on chromosome within their family. 17, and BRCA2, which is She has mentioned on chromosome 13. that her cousin has Mutation of these genes experienced similar results in the failure to fix problems and had DNA damage, and the her breast removed cells harboring damaged for the same DNA survive and keep reason. proliferating and leads to the increasing risks of cancer. If either parent has a mutation on either the 31  BRCA1 or BRCA2 gene, there is a 50 percent chance they will pass it on to their offspring. This is called autosomal dominant inheritance; that is, only one copy of the mutated gene is enough to raise cancer risk. Gender Being female is the most PRESENT Patient falls under significant risk factor for the vulnerable breast cancer. Women group– females, at have more breast cells risk for developing than men, and these cells invasive ductal are more frequently carcinoma. In which exposed to hormones like according to estrogen and research, females progesterone, which have excessive promote cell growth hormonal exposure (Jenlmat, 2020) compared to men potentiates mutations and may increase risk of developing cancerous changes. Early onset of Early menarche leads to a ABSENT Patient had her menstruation longer duration of onset of menarche (HORMONAL exposure to estrogen and at 13 years old FACTOR) progesterone over a which is within the woman's lifetime. These normal age for hormones play significant females to start 32  roles in breast tissue their menstruation. development and cell proliferation. Early menarche generally means more menstrual cycle and each cycle involves hormonal fluctuations thst stimulate breast tissue growth and division. Thus increase the likelihood of mutations that lead to cancer Late Women with late ABSENT Patient, now 56 Menopause menopause often have years old, had her other reproductive menopause 3 years characteristics that ago– 53years old heighten breast cancer which does not risk risk, such as early her to longer menarche (onset of hormonal exposure. menstruation) and fewer pregnancies. Research indicates that for every year a woman delays menopause, her risk of breast cancer increases by approximately 3%. These factors collectively contribute to a longer reproductive window, further increasing estrogen exposure 33  PRECIPITATING FACTORS FACTOR RATIONALE REMARKS JUSTIFICATION Sedentary A sedentary lifestyle ABSENT Patient grew up in a Lifestyle increases cancer risk by farm so she is often contributing to obesity, subject to physical which promotes work. She alsoc inflammation and managed a fruit hormone production shake business linked to cancer. It also which require a lot causes insulin of physical activity. resistance, elevating Patient considers insulin levels that her work and encourage cell growth. household tasks as Chronic inflammation can her exercise. damage DNA, and inactivity weakens immune function, reducing the body's ability to fight cancer. Regular exercise is essential for lowering these risks. Obese/Overwei Obesity increases cancer ABSENT Patient maintained a ght risk due to several normal Body Mass factors: it leads to higher Index before and levels of hormones like after diagnosis of estrogen and insulin, cancer and which can promote cell procedure. growth. Excess fat also produces inflammatory substances that can 34  damage DNA and support tumor development. Additionally, obesity is linked to metabolic changes that create an environment conducive to cancer progression. High-energy The foods we eat can ABSENT Patient often eat and high-fat affect our risk of fruits because of Diet developing certain types growing up on a of cancer. High-energy farm. Even in her and high-fat diets can adulthood she sells lead to obesity and are fruit shakes and generally thought to often incorporates increase the risk of some vegetables on her cancers. Processed meals. meats, low fruit and vegetable intake, high sale and preserved foods, cooking methods and etc, all contribute to possible development of cancer on late age. Smoking or Studies indicate that ABSENT Patient mentioned second hand women exposed to there are no smoke secondhand smoke have smokers in their a higher risk of family so she has developing breast not been exposed to cancer, particularly a lot of secondhand 35  premenopausal women. smoke. One meta-analysis reported an odds ratio of 1.235 for breast cancer risk associated with secondhand smoke exposure. Exposure to secondhand smoke during childhood as well has been linked to an 11% increased risk of breast cancer in adulthood among never-smokers. This suggests that early exposure may have long-lasting effects on breast tissue development and cancer risk Alcohol Use Alcohol is empty calories ABSENT Patient does not and can lead to drink alcohol, but unwanted weight gain. mentioned she has Excess fat can lead to drank few times increased cancer risk. It before when she can increase levels of was younger. estrogen and other hormones associated with breast cancer. Alcohol users are more likely to have increased amounts of folic acid in 36  their systems, which can lead to increased cancer risk. Exposure to Type of radiation used, ABSENT Patient has not radiation age of exposures, cause been exposed to increase risk of any heavy radiation developing cancer. other than her Ionizing radiations can average exposure to cause direct damage to her mobile phone. the DNA within breast She mentioned she cells leading to mutations only had been that may initiate cancer hospitalized four development. This times (UTI, Birth of includes mutagenesis her children, and the and the induction of now admission) and genomic instability. has not underwent any serious laboratory test that exposed her to heavy radiation until she was diagnosed. 37  B. SYMPTOMATOLOGY SYMPTOMATOLOGY FACTOR SIGNS AND SYMPTOMS REMARKS JUSTIFICATION Changes in Breast ABSENT The presence of a tumor can appearance pull on the surrounding tissue, leading to skin changes such as dimpling or puckering. This phenomenon, often described as "peau d'orange," occurs when the skin overlying the tumor becomes thickened and dimpled, resembling an orange peel. Tumors can cause localized swelling or an overall change in breast size. This is due to the mass of the tumor itself or fluid accumulation (edema) in response to inflammation or lymphatic obstruction caused by cancer Breast or Nipple pain ABSENT Patient had no complaints of pain of her breast which led her to not seek for consultation. However, due to family history, patient sought consultation after 5 months of consistent lump, and was later diagnosed with invasive ductal carcinoma. According to Dr.Sheikh (2024), lump or mass in the breast is the most common symptom of 38  breast cancer. They are often painless, howver some individuals may experience discomfort due to the tumor pressing on surrounding thissue or nerves. Additionally, inflammataroy breast cancer can cause significant pain and swelling. Discharge from the nipple ABSENT Abnormal discharge can occur due to changes in the ducts caused by cancerous cells. Tumors may block milk ducts, leading to fluid buildup and discharge, which can be clear, bloody, or yellow 34. Conditions like Paget's disease of the nipple, associated with breast cancer, also lead to discharge and skin changes around the nipple (Nall, R., & Ames, H., 2024) A lump in the breast PRESENT Patient has noticed a lump on tissue her breast 5 months prior to admission. The most common sign of breast cancer is a lump or mass within the breast tissue. This occurs when cancerous cells proliferate and form a distinct mass that can often be felt during self-examination 45. The lump 39  may feel hard or rubbery and is typically different from surrounding tissue. (Underferth, 2019) Lump/s in the underarm ABSENT Breast cancer can spread to area nearby lymph nodes, particularly those in the underarm area (axillary lymph nodes). When cancer cells invade these lymph nodes, they may become swollen and palpable as lumps 23. This is often one of the first signs indicating that breast cancer has spread beyond its original site. (Nall, R., & Ames, H., 2024) Scaly or flaky skin on the ABSENT Cancer can lead to skin nipple or an ulceration alterations such as scaling, (sore) on the skin of the redness, or ulceration due to breast or nipple direct invasion of cancer cells into the skin or as a reaction to the tumor's presence. Inflammatory breast cancer is particularly known for causing such severe skin changes 123. Ulceration occurs when tumors grow aggressively and outgrow their blood supply, leading to necrosis (tissue death) at the surface.. (Nall, R., & Ames, H., 2024) 40 C. SCHEMATIC TRACING 41 42 43  D. NARRATIVE Invasive Ductal Carcinoma (IDC) involves both predisposing factors (non-modifiable) and precipitating factors (modifiable) present in the patient. The predisposing factors include age (the patient is over 55), genetic factors (such as history of cancer on maternal side ), gender (the patient is female), early onset of menstruation, and late menopause, all of which are present in the patient. Conversely, the precipitating factors that are not present in the patient include a sedentary lifestyle, obesity, poor diet, smoking, alcohol use, and exposure to radiation. These factors eventually lead to genetic mutations in ductal epithelial cells. Ductal epithelial cells are specialized cells that line the ducts of breast, which forms the lining of the milk ducts and are responsible for transporting milk from the lobules (where it's produced) to the nipple. The genetic mutations involve BRCA1 & BRCA2, HER2, and TP53. BRCA1 and BRCA2 are tumor suppressor genes responsible for repairing DNA. Mutations lead to its loss of function, allowing damaged cells to survive (cellular senescence). HER2 protein is involved in signaling pathways that regulate cell growth, division, and survival. Overexpression of the HER2 protein promotes cell growth and division. The TP53 gene makes a protein called p53 that helps stop cancer by fixing damaged DNA, preventing unhealthy cells from growing, and triggering cell death if the damage is too severe. Mutations in TP53 disrupt normal apoptosis (programmed cell death), allowing abnormal cells to persist. All in all, these genes contribute to increased cell proliferation and loss of apoptosis. These mutated cells begin to exhibit abnormal morphology (irregular shapes and sizes) of cells. Which leads to retention of the basement membrane where cells remain contained within the ductal structure, ultimately leading to the development of Ductal Carcinoma in Situ which is a localized mass within the ducts. This manifests noticeable signs such as lump in the breast tissue, nipple discharges, changes in breast appearance (shape/size). Diagnostic exams that could help detect DCIS when symptoms manifest are mammography, ultrasound, Magnetic Resonance Imaging (MRI), Biopsy, Histopathological Examination, and Immunohistochemistry. 44  Later on, when Ductal Carcinoma is not diagnosed, it can advance to other stages. First, there would be a secretion of metalloproteins, leading to the degradation of the basement membrane and extracellular matrix, which makes tissue's structural integrity compromised. Cells then shift from being tightly packed, like cells in a layer (epithelial cells), to being more spread out and flexible (mesenchymal cells). This process is called epithelial-to-mesenchymal transition (EMT) and promotes cells to move around freely. In addition low levels of E-cadherin decreases cell to cell adhesion, promoting motility. All of these allows cancer cells to migrate into the surrounding stroma. Once cancer cells invade the stroma, they continue to proliferate, forming an invasive tumor. This invasive tumor can be classified now as Invasive Ductal Carcinoma. This will manifest symptoms as, nipple and breast pain, swelling, nipple discharges, dimpled or puckered skin, nipple inversion, swollen lymph nodes, and scaly or flaky skin on the nipple. Invasive Ductal Carcinoma can both lead to bad and good prognosis. It can be well treated with various treatment options depending on the case of the patient. One kind of treatment is to remove the tumor, more known as a lumpectomy or breast-conserving surgery, where the tumor and some nearby tissue are removed. This further helps alleviate this risk by using adjuvant chemotherapy, which removes all possible remaining cancer cells that may be left in the body. Chemotherapy can also be administered if the cancer has aggressive properties or if it spreads to the lymph nodes. Alternatively, a mastectomy may be recommended. In this, one or both breasts are completely removed, depending on how widespread the cancer is. Usually, after mastectomy, a biopsy of the sentinel lymph node is performed to check if the cancer has spread to other cells in nearby lymph nodes. It becomes important to locate and remove the first lymph node(s) that the breast flows into to ensure appropriate staging of this cancer and to decide on further treatment. This measures can lead to overall good prognosis. On the other hand, if left untreated, the invasive tumor can interact with surrounding fibroblasts and immune cells, which secrete growth factors like TGF-β that further promote cancer cell proliferation and survival. As the tumor grows, its demand for nutrients and oxygen increases, triggering the release of pro-angiogenic factors such as VEGF, which stimulate the formation of new 45 blood vessels (angiogenesis). Additionally, cancer cells produce cell adhesion molecules that facilitate intravasation, the process by which they invade nearby lymphatic or blood vessels and enter the bloodstream. Some cancer cells evade the immune response by altering surface antigens or secreting immunosuppressive factors, allowing them to survive in the bloodstream. This leads to extravasation, where cancer cells exit the bloodstream, adhere to endothelial cells in distant organs, and establish secondary tumors. These metastatic tumors often form in the bones, lungs, liver, or brain, leading to multiple organ failure. Without proper management, this progression results in a poor prognosis and can ultimately lead to death. 46 VI. MEDICAL MANAGEMENT A. DIAGNOSTIC EXAMS AND LABORATORY TESTS a. ACTUAL TESTS DONE 1. Laboratory Exam 1A. BLOOD CHEMISTRY The bilirubin blood test evaluates the concentration of bilirubin in the bloodstream. Bilirubin is a yellow pigment that is present in bile, a substance produced by the liver. This test is used to find out how well your liver is working. It is often part of a panel of tests that measure liver function. A small amount of bilirubin in your blood is normal, but a high level may be a sign of liver disease (UMRC, 2023). DATE COMPON DEFINITION/R NORMAL RESUL INTERP NURSING RESPONSIBILITIES ENT ATIONALE FINDING TS RETATI S ON & SIGNIFI CANCE Septe Total This measures Total 6.60 NORM 1. Explain the purpose of mber BIlirubin the overall Bilirubin: umol/L the bilirubin test. AL 30, amount of 5.1-20.5 R: Proper education helps 2024 bilirubin in the umol/L This reduce patient anxiety, blood, including level is promotes cooperation both direct and within indirect forms. the 2. Instruct the patient not to Elevated levels normal eat or drink at least 4 can indicate range hours before the test. 47  liver for R: Fasting may be required dysfunction, adults, to prevent food or hemolysis, or which medications from affecting bile duct typically bilirubin levels, which obstruction. It is less ensures the accuracy of the serves as a key than test indicator of liver 20.5 health and µmol/L. 3. purpose of the bilirubin helps diagnose Elevate test. conditions like d total R: Proper education helps jaundice, bilirubin reduce patient anxiety, hepatitis, or may promotes cooperation cirrhosis suggest liver 4. Instruct the patient not to dysfunc eat or drink at least 4 tion or hours before the test. hemoly R: Fasting may be required sis if to prevent food or significa medications from affecting ntly bilirubin levels, which higher. ensures the accuracy of the test results. Direct Also known as Direct 1.60 NORM 5. Assess the patient for Bilirubin conjugated Bilirubin: umol/L signs of jaundice AL (yellowing of the skin or bilirubin, this 0.5-5. 1 form is umol/L This eyes), dark urine, pale water-soluble stools, and other result is symptoms of liver and indicates bilirubin that within dysfunction. has been the R: Monitoring for clinical processed by the liver. High normal signs of elevated bilirubin levels suggest provides valuable range of information about the issues such as severity of liver dysfunction. 48 bile duct direct obstruction or bilirubin liver disease, as it reflects the. This liver's ability to indicate conjugate bilirubin for s the excretion liver is process ing bilirubin effectiv ely 49 Indirect This is the Indirect 5 NORM bilirubin Bilirubin: umol/L unconjugated AL 0.0-19.0 form of bilirubin umol/L This is that is not the water-soluble unconju and is bound to gated albumin in the form of bloodstream. It bilirubin indicates the that is breakdown of not red blood cells. water-s Elevated levels oluble can be a sign of and is hemolytic bound anemia or other to conditions albumin where the liver in the cannot process bloodstr bilirubin quickly eam. It enough indicate s the breakdo wn of red 50  blood cells. Elevate d levels can be a sign of hemolyt ic anemia or other conditio ns where the liver cannot process bilirubin quickly enough Alkaline This enzyme is Alkaline 66.00 NORM hosphatas Phosphat u/l found in various AL e ase: tissues, with 33-98 U/L This 51 high value concentrations falls in the liver and within bones. Elevated the ALP levels can normal indicate liver range disease, bile (typicall duct y 44 to obstruction, or 147 U/L bone disorders. for It is often adults). included in liver Normal function tests to ALP assess overall suggest hepatic health s that there are no significa nt issues with bile duct obstruct ion or 52 liver function. 53 1B. IMMUNOLOGY This test is used in laboratories to produce artificial antibodies that exactly match the substance. Used to diagnose congenital or acquired diseases of the immune system or monitor the progression of an existing medical condition, such as certain types of cancer wherein PSA levels in the blood are monitored (Institute for Quality and Efficiency in Health Care, 2021). The test is usually done in cancer patients to assess thyroid function if the cancer cells have been affected or have progressed in thyroid-stimulating hormone. DATE COMP DEFINITION/RATI NORMA RESULTS INTERPRETATION NURSING ONEN ONALE L & SIGNIFICANCE RESPONSIBILITI T FINDIN GS ES Septe Free T3 represents only 1.58-3.9 Free T3: NORMAL Explain the mber T3 5% of all the 1 pg/mL 2.85 pg/mL purpose of the Free T3 within the 30, hormones released thyroid function 2024 by the thyroid. normal range test, how it Thyroid hormones assesses thyroid indicates that the mediate their hormone levels effects on cancer thyroid gland is (e.g., T3, T4, and development and TSH). functioning properly progression are R: Helps the affected by in producing the patient understand dysregulation of the the relevance of adequate amount of local bioavailability the test in relation