Our Lady of Fatima University College of Nursing Regalado, Fairview Quezon City

HOSPITAL OF AFFILIATION: PNPGH AREA/WARD: Male Surgical Ward DATE OF CLINICAL EXPOSURE: May 19-21- 26, 26-28 DAY AND TIME OF DUTY EXPOSURE: Monday 07:00am-03:00pm

NARRATIVE REPORT

Its our third rotation of duty for NCM 103, we are assigned in PNPGH at Male Surgical Ward under Ms. Rosel Estuaria, our Clinical Instructor. The nurses and doctors are nice and approachable. I noticed that most of the patients are well respected and easy to handle because they cooperate. During our clinical duty Ms. Estuaria taught us on plotting, doing FDAR, how to regulate IVF, and so on. She also gave us pre and post test regarding medical abbreviation and drug study and we have an individual case presentation. We also have to pass a case presentation as a requirement for NCM 103. In my overall experience in PNPGH, I can say that Id like to have another duty in the different areas of this hospital.

Jennifer Pingco ______________ Student Signature

Our Lady of Fatima University College of Nursing Regalado, Fairview Quezon City

HOSPITAL OF AFFILIATION: PNPGH AREA/WARD: Male Surgical Ward DATE OF CLINICAL EXPOSURE: May 19-21- 26, 26-28 DAY AND TIME OF DUTY EXPOSURE: Monday 07:00am-03:00pm PATIENT PROFILE NAME: Panao, Dominador ADDRESS: Brgy. Poblacion, Mariveles, Bataan DATE ADMITTED: May 11, 2011 DR. INCHARGE: Dr. Domingo/Dr. Tolentino DIAGNOSIS: bladder mass NURSING HISTORY PRESENT MEDICAL HISTORY: Diagnosed of UV mass sore, positive weakness and hematoma hence consult at PNPGH ER then admission PAST MEDICAL HISTORY: Allergies: None. PATHOPHYSIOLOGY DEFINITION: Bladder cancer is a disease in which the cells lining the urinary bladder lose the ability to regulate their growth and start dividing uncontrollably. This abnormal growth results in a mass of cells that form a tumor. Pathologic Stage These are the main features of each stage of the disease:

Stage 0 -- The cancer cells are found only on the surface of the inner lining of the bladder. The doctor may call this superficial cancer or carcinoma in situ. Stage I -- The cancer cells are found deep in the inner lining of the bladder. They have not spread to the muscle of the bladder. Stage II -- The cancer cells have spread to the muscle of the bladder. Stage III -- The cancer cells have spread through the muscular wall of the bladder to the layer of tissue surrounding the bladder. The cancer cells may have spread to the prostate (in men) or to the uterus or vagina (in women). Stage IV -- The cancer extends to the wall of the abdomen or to the wall of the pelvis. The cancer cells may have spread to lymph nodes and other parts of the body far away from the bladder, such as the lungs. Bladder cancer is often described as a polyclonal field change defect with frequent recurrences due to a heightened potential for malignant transformation. However, bladder cancer has also been described as resulting from implantation of malignant cells that have migrated from a previously affected site. In its place, the term nonmuscle-invasive bladder cancer should be used and qualified with the appropriate American Joint Committee on Cancer stage (ie, Ta, T1, Tis). Stage T1 cancer invades lamina propria but not the muscle of the bladder. Transitional cell carcinoma Transitional cell carcinoma (TCC) arises from stem cells that are adjacent to the basement membrane of the epithelial surface. Depending on the genetic alterations that occur, these cells may follow different pathways in the expression of their phenotype. The most common molecular biologic pathway for TCCs involves the development of a papillary tumor that projects into the bladder lumen and, if untreated, eventually penetrates the basement membrane, invades the lamina propria, and then continues into the bladder muscle, where it can metastasize. Nearly 90% of transitional cell bladder tumors exhibit this type of behavior. This progression only occurs with high-grade cancers. Low-grade cancers rarely, if ever, progress and are thought to have a distinct molecular pathway, different from the highgrade cancers and CIS. The remaining 10% of TCCs follow a different molecular pathway and are called CIS. This is a flat, noninvasive, high-grade urothelial carcinoma tumor that spreads along the surface of the bladder and, over time, may progress to an invasive form of cancer that behaves the same as invasive TCC. Many urothelial tumors are primarily composed of TCC but contain small areas of squamous differentiation, squamous cell carcinoma (SCC), or adenocarcinoma.

Squamous cell carcinoma SCC of the urinary bladder is a malignant neoplasm derived from bladder urothelium with pure squamous phenotype. SCC of the bladder is essentially similar to squamous cell tumors arising in other organs. Because many urothelial carcinomas contain a minor squamous cell component, a diagnosis of SCC of the bladder should be rendered only when the tumor is solely composed of squamous cell components, with no conventional urothelial carcinoma component. Reportedly, SCC has less of a tendency for nodal and vascular distant metastases than urothelial carcinoma. Rare forms of bladder cancer Adenocarcinomas account for less than 2% of primary bladder tumors. These tumors are observed most commonly in exstrophic bladders and are often associated with malignant degeneration of a persistent urachal remnant. Other rare forms of bladder cancer include leiomyosarcoma, rhabdosarcoma, carcinosarcoma, lymphoma, and small cell carcinoma. Carcinosarcomas are highly malignant tumors that contain both mesenchymal and epithelial elements. Primary bladder lymphomas arise in the submucosa of the bladder. Leiomyosarcoma is the most common sarcoma of the bladder. Rhabdomyosarcomas most commonly occur in children. Except for lymphomas, all these rare bladder cancers carry a poor prognosis. Small cell carcinoma of the urinary bladder is a poorly differentiated malignant neoplasm that originates from urothelial stem cells and has variable expression of neuroendocrine markers. Morphologically, it shares the same features of small cell carcinoma of other organs, including small cell carcinoma of the lung. Genetic pathophysiology As with all cancers, bladder cancer is associated with oxidative DNA genetic changes in the host cells, leading to abnormal and potentially uncontrolled growth. The TP53 tumor suppressor gene and band 9p21, a locus known to be the site of a significant tumor suppressor gene, are two of the most common and significant missing or mutated gene/gene sites in many patients with bladder cancer. In addition, tumor suppressor genes P15 and P16 on chromosome 9, the RB tumor suppressor gene, the erb -b2 oncogene, and the p21-ras, c-myc, and c-jun genes may be mutated. Aneuploidy of chromosomes 3, 7, and 17 is also present in many patients with bladder cancer and may be readily detected using fluorescent in situ hybridization (FISH).

MEDICAL MANAGEMENT FOR PAIN The goal of pain management is not only relief from pain, but also the maintenance of your normal quality of life. All methods of pain management attempt to either control the cause of the pain or alter your perception of it. Although pain management techniques are many and varied, therapeutic approaches can be classified as either pharmacological or non-pharmacological. Pharmacological pain control involves the use of analgesics, as well as other medications that intensify the analgesics' effects or modify your mood or pain perception. Non-pharmacological approaches include:

Behavioral techniques Radiation Surgery Neurological and neurosurgical interventions Traditional nursing and psychosocial interventions

The latter measures attempt to promote your comfort and evaluate the effectiveness of the therapy. Because of the complex nature of cancer-related pain, successful management usually involves a combination of techniques.

NURSING MANAGEMENT 1. 2. 3. 4. 5. Encourage the patient to express feelings and concerns about the extent of the cancer. To relieve discomfort administer ordered analgesics for pain as necessary. Implement comfort measures and provide distractions that will enable the patient to relax. As appropriate, implement measures to prevent or alleviate complications of treatment. Monitor the patients intake and output. Question him regularly about changes in his urine elimination pattern to detect changes in his condition. 6. Observe the patients urine for signs of hematuria (reddish tint to gross bloodiness). 7. Monitor the patients laboratory tests, such as changes in white blood cell differential, indicating possible bone marrow suppression from chemotherapy. 8. If the patient is being given intravesical chemotherapy, watch closely for myelosuppression, chemical cystitis, and skin rash. 9. Instruct the patient and the family about the types of treatment that are being planned for him. 10. Stress the importance of notifying the doctor if the patient develops signs and symptoms of urinary tract infection or other sudden changes in his condition.

DIAGNOSTIC PROCEDURE Urinalysis / Cytology Urine cultures often fail to detect malignancy, and cytologic studies can be of more help as a diagnostic tool. However, these tests are less than accurate, and due to a rather high rate of false negatives, cannot exclude the possibility of malignancy. The tests in use are less accurate in detecting low grade TCC, though a postive result would almost always indicate a malignancy. Utrasound (US) Ultrasonography uses sound waves for imaging, and though imaging is recorded on film similar to x-ray film, there is no radiation exposure. Ultrasonography has limitations in detail and specificity as compared to other imaging modalities. Oral medications: Dolcet 325mg TID IVF: PNSS 1LX KVO Furosemide 40mg given through slow IVF