DOÑA REMEDIOS TRINIDAD ROMUALDEZ MEDICAL FOUNDATION, INC.

COLLEGE OF NURSING
2nd Semester, S.Y. 2020 - 2021

Ardel Berenice C. Labada

BSN 3 – B
Clinical Group C

PATIENTS HISTORY

GENERAL DATA:
Name: Patient P
Age: 65-year-old
Birthday: May 23, 1956
Address: Abuyog Leyte
Birthplace: Abuyog Leyte
Nationality: Filipino
Civil Status: Married
Religion: Roman Catholic
Educational Attainment: College graduate
Admission Date: September 2, 2021
Admission Time: 3:25 PM
Admission Diagnosis: Massive ascites from liver metastasis from breast cancer;R/O
Peritoneal Carcinomatosis; Breast Cancer right;S/P chemotherapy x 8 cycles; covid-19
suspect
Chief Complaint: Increased abdominal girth & exertional dyspnea

DEFINITION OF THE DISEASE

Breast Cancer
 Breast cancer is a disease in which cells in the breast grow out of control. There are
different kinds of breast cancer. The kind of breast cancer depends on which cells in
the breast turn into cancer.
 Metastatic breast cancer (also called stage IV) is breast cancer that has spread to
another part of the body, most commonly the liver, brain, bones, or lungs.
  Cancer cells can break away from the original tumor in the breast and travel to other
parts of the body through the bloodstream or the lymphatic system, which is a large
network of nodes and vessels that works to remove bacteria, viruses, and cellular
waste products.

Liver Metastasis
 Liver metastases are cancerous tumors that have spread (metastasized) to the liver
from another part of the body. These tumors can appear shortly after the original
tumor develops, or even months or years later.
 The liver is a common site for metastatic disease because of its rich, dual blood
supply (the liver receives blood via the hepatic artery and portal vein). Metastatic
tumors in the liver are 20 times more common than primary tumors

SYMPTOMS OF LIVER METASTASES

 It can be hard to recognize symptoms and signs that cancer has spread to your liver.
 Many people don’t notice anything unusual to indicate that they’ve developed liver
metastases. Some say they feel some abdominal discomfort or pain.
 Feeling of weakness and poor health
 Loss of appetite
 Weight loss
 Fever
 Fatigue
 Bloating
 Itching
 Swelling of the legs (edema)
 yellowing of the skin or whites of the eyes (jaundice)

THERAPEUTIC MANAGEMENT
 Metronidazole for surgical prophylaxis for anaerobic enteric microorganisms.
 Spironolactone for promoting sodium and water excretion, increasing potassium
retention
 Human Albumin replacement in patients with albumin & blood deficiency
 Paracetamol treat aches and pain
 Mannitol is to treat oliguria
MEDICAL MANAGEMENT
 PNSS 1L at 60 cc/hour
 O2 therapy
DIET MANAGEMENT
 Low salt Na , 2g/ day