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Case Study
Case Study
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I.
Introduction
The incidence of esophageal cancer is on the rise with over 2,000 Filipinos and 12,000 Americans developing this disease each year .Variations in the incidence of esophageal cancer are seen with age, sex, and race. Advances in medical and surgical therapy have led to improvement in the survival rates but continued improvement in survival is dependent on a better understanding of the relationship between environmental factors and the disease itself. The incidence of esophageal cancer fluctuates dramatically throughout various regions of the world and has the largest variability of any known malignancy. High rates are found in people living in northeast China to north central Asia, Afghanistan and northern Iran. Other high-risk groups include the white population in parts of South Africa and areas of Finland, Iceland, and France. In the United States, trends demonstrate that black men have a fourfold greater incidence than white men for squamous cell esophageal cancer with significant variation in locale, nutritional status, socioeconomic status, and alcohol and cigarette use. Esophageal cancer is malignancy of the esophagus. It is a typically carcinomas which arise from the epithelium, or surface lining, of the esophagus. Most esophageal cancers fall into one of two classes: squamous cell carcinomas, which are similar to head and neck cancer in their appearance and association with tobacco and alcohol consumption, and adenocarcinomas, which are often associated with a history of gastroesophageal reflux disease and Barrett's esophagus. A general rule of thumb is that a cancer in the upper twothirds is a squamous cell carcinoma and one in the lower one-third is a adenocarcinoma. Rare histologic types of esophageal cancer are different variants of the squamous cell carcinoma, and non-epithelial tumors, such as leiomyosarcoma, malignant melanoma, rhabdomyosarcoma, lymphoma and others. Signs and Symptoms
Difficulty swallowing Feelings of fullness, pressure, and burning as food travels down the esophagus The sensation of having a piece of food stuck behind the breastbone Weight loss, caused by a change in eating habits, which is in turn due to the discomfort from other esophageal cancer symptoms such as heartburn, indigestion, and vomiting Regurgitation of food Coughing and hoarseness Blood found in vomit
Risk Factors Increased risk There are a number of risk factors for esophageal cancer. Some subtypes of cancer are linked to particular risk factors:
Age - most patients are over 60, and the median in US patients is 67. Sex - the disease is more common in men. Heredity - it is more likely in people who have close relatives with cancer. Tobacco smoking and heavy alcohol use increase the risk, and together appear to increase the risk more than either individually. Tobacco and/or alcohol account for approximately 90% of all esophageal squamous cell carcinomas. Tobacco smoking is also linked to esophageal adenocarcinoma though no scientific evidence has been found between alcohol and esophageal adenocarcinoma. Gastroesophageal reflux disease (GERD) and its resultant Barrett's esophagus increase esophageal cancer risk due to the chronic irritation of the mucosal lining. Adenocarcinoma is more common in this condition. Human papillomavirus (HPV) Corrosive injury to the esophagus by swallowing strong alkalines (lye) or acids Particular dietary substances, such as nitrosamines A medical history of other head and neck cancers increases the chance of developing a second cancer in the head and neck area, including esophageal cancer. Radiation therapy for other conditions in the mediastinum Obesity increases the risk of adenocarcinoma fourfold. It is suspected that increased risk of reflux may be behind this association. Alcohol consumption in individuals predisposed to alcohol flush reaction Decreased risk
Risk appears to be less in patients using aspirin or related drugs (NSAIDs). The role of Helicobacter pylori in progression to esophageal adenocarcinoma is still uncertain, but, on the basis of population data, it may carry a protective effect. It is postulated that H. pylori induces chronic gastritis, which is a risk factor for reflux, which in turn is a risk factor for esophageal adenocarcinoma.[ According to the National Cancer Institute, "diets high in cruciferous (cabbage, broccoli/broccolini, cauliflower, Brussels sprouts) and green and yellow vegetables and fruits are associated with a decreased risk of esophageal cancer." Moderate coffee consumption is associated with a decreased risk.
OBJECTIVES: To review the various treatment approaches, complications, and nursing management of patients with esophageal cancer.
I. Biographic Data
Name: Mrs. N.S Age: 67 Gender: Female Address: Masambong, Quezon City Date of Birth: 10/24/1944 Occupation: Street vendor Religious Affiliation: Roman Catholic Marital status: Widow ADMISSION DATA Admission Date and Time: Jan. 26, 2012; 4:30 am Hospital: Jose Reyes Memorial Medical Center\ Chief Complaint: Dysphagia Diagnosis: T/C ENG, Esophageal Cancer Attending Physician: Dr. M. C.
Patterns
Before Hospitalization
During Hospitalization
The Patient has IUD contraceptive, she verbalized, Nagpalagay ako ng IUD tatlompung(30) taon na pagkatapos ko manganak sa bunso ko kasi walo(8) na ang anak ko. Her health is important to her she verbalized, Patay na ang asawa ko, at namatayan na din ako ng isang anak kaya kailangan ko alagaan ang kalusugan ko kasi kailangan pa ako ng mga anak ko kahit matatanda na sila .
Health Perception
Self-concept is ones mental image of oneself. A positive self-concept is essential to a persons mental and physical health. Individuals with a positive self- There were no concept are better able changes in the health to develop and perception of the maintain interpersonal patient. She relationships and resist verbalized, ang psychological and gusto ko lang ay physical illness. An gumaling na , ayaw individual possessing a ko dito sa ospital strong self-concept nanghihina ako pag should be better able to nandito ako accept or adapt to changes that may occur over the life span. How one views oneself affects ones interaction with others. - She wants to take away the IUD, she verbalized, may sumasakit na sa puwera ko, gusto ku na ipatanggal ung IUD. The patient dont likes to eat the food rationed by the hospital, the patient verbalized wala namang lasa mga pagkain dito sa ospital kaya nagpapabili ako sa
Nutrition
Has a very good appetite; eats 2 cup of rice per meal Eats 3x/day and sometimes even eats biscuits for snacks Very fond of eating vegetables , meat, chicken, etc.. And as
an alternative, they labas. Lalo ako are fond of eating manghihina sa mga canned goods pagkain dito. specially sardines if She always asks they dont have significant others to money buy her some food drinks approximately from outside the 6 cups of water, drink hospital coffee everyday. Patient drinks weighs approximately 3 approximately 150 bottles of lbs water/day, she also drink milk (Ensure) because of the doctors order.
Elimination
Exercise
Hygiene
urinates without urinates more difficulty and frequently experiences no pain Urinates around when voiding 250 cc per shift urine is light amber Not defecating or in color, is aromatic, constipated since and adequate in the admission. amount voids 5-6x/day defecates once every morning without pain and difficulty stool is light brown to brown in color, semi-solid in consistency, soft and tubular sits on the chair most lying on bed most of the time while of the time watching TV Cant perform considered washing ROM exercises clothes as her only because she exercise experiences pain doesnt have time to when moving her exercise extremities. Unable to perform ADL bathes once never taken a full everyday, shampoos bath since she was
ABNORMAL. CONSTIPATED Urination, Freshly voided urine is generally clear in appearance and pale to deep yellow. When formed, urine is sterile and aromatic.
ABNORMAL. For exercise to be effective, it should be regular and sustained. Generally, exercising at least thrice a week is advised.
ABNORMAL.
hair and cleanses body with soap and towel without helper. brushes teeth 2x a day gets fingernails cleaned and trimmed changes clothes everyday combs hair everyday
hospitalized daily regimen includes using towel with soap to wipe clean the body parts Always combing her hair. Brushes teeth 1x a day. Fingernails is not trimmed.
Bathing provides relaxation and comfort and it gives moat people a sense of wellbeing. Nails should be trimmed as needed. Regular check-ups ensure the health of the teeth and gums. Normal grooming patterns includes daily brushing and combing of hairs. NORMAL. Nicotine causes many harmful physiologic effects and is a precursor of lung cancer and coronary artery diseases. Nicotine has a stimulating effect on the body and smokers often have more difficulty falling asleep than non smokers. Smokers are usually easily aroused and often describe themselves as light sleepers. ABNORMAL The sleep wake cycle is very important to adults. The usually have an active lifestyle, and are thought to require 7 to 8 hours of sleep each night by may do well
does not smoke cigarettes does not drink alcoholic beverages does not use any forms of recreational drugs
does not smoke cigarettes does not drink alcoholic beverages does not use any forms of recreational drugs
5. Substance Use
usually sleeps at the patient cant around 8 or 9 pm and sleep easily due to wakes up at 7 to 7:30 uncomfortable am place. describes sleep as wakes up for vital complete and stated signs feeling relaxed after describes sleep as waking up incomplete and sleeps soundly and feels tired even
describes sleep as deep Does not nap during the afternoons or any time of the day besides night time. The patient graduated in 4th year high school. Because of financial problem shes not be able to continue her studies. When I asked her cognitive skills, she doesnt have any difficulty in understanding verbal or written instructions. She can also read and write. As to her sense of hearing, she can hear clearly in her both ears. During the interview, the patient was able to remember memories from her early years up to the most recent.
after waking up Sleeps lightly and is easily awaken by disturbances in the environment There were no changes in the cognitive perception of the client.
Normal Transition means adjustment to new interest, new values and new patterns of behavior. In middle adulthood, sooner or later, all adults must make adjustments to physical changes and must realize that the behavioral patterns of their younger years have to be radically revised.
Cognitive Patterns
The patient was widowed 5 years ago. Her Husband died due to heart attack. When asked her relationship with her siblings she verbalized, ako ang nag alaga sa lahat ng anak ko, alam ko na di ako nagkukulang sakanilang lahat kahit sila ay marami, mababait ang mga anak ko. Noong Role and Relationship Pattern namatay ang asawa ko lahat sila nagtulungan para mabuhay kami.
There were no changes to role and relationship of the patient as verbalized by the son
Normal The effectiveness if family communication determines the familys ability to function cooperative, growth-producing unit. Messages are constantly being communicated among family members both verbally and nonverbally. The information transmitted influences how members work together, fulfill their assigned roles in the family, incorporate family values and develop skills to function in society. Intra-family communication plays a significant role in the development of selfesteem which is necessary for the growth of personality.
NORMAL. At any time in life, physical, psychological and social problems may a profound effect on a persons expression of sexuality. This should
Sexual Activity
be taken into account when it involves a persons health or the delivery of care. People who do not have active sex life still express sexuality in their clothes, grooming, activities and roles.
The son verbalized, bukod sa paglalaba ay mahilig sumayaw at kumanta si nanay. Kapag wala naman siyang ginagawa ay nakikinig lang siya ng radio o nanunuod ng TV lalo na kapag Wowowee na.
Patient was in compete bed rest. Patient sleeps lightly and is easily awaken by disturbances in the environment
Normal, since the client adapted to changes. Recreation or fun is the expenditure of time in a manner designed for therapeutic refreshment of one's body or mind. It contributes to life satisfaction, quality of life, health and wellness, and that the use of recreation as a diversion may have clinical applications to individuals with chronic pain and other health impairment. It is essential to the longevity of human beings, especially because it helps counteract stress.(Encyclopedia of
Coping/Stress Tolerance
Occupational Health and Safety) She does always go to the church every Friday and Sunday with some of her daughter. The patient prays everyday for her fast recovery. Ang pinapanalangin ko lang nman ay gumaling na ako . Normal Value is a concept that describes the beliefs of an individual or culture. A set of values may be placed into the notion of a value system. Values are considered subjective and vary across people and cultures. Types of values include ethical/moral values, doctrinal/ideological (political, religious) values, social values, and aesthetic values. It is debated whether some values are innate.
V. Physical Assessment
Method Norms Actual Findings Interpretation and Analysis
Inspection
Poor gait
Deviation from normal, the patient has a poor gait due to joint pain
2. Skin Color
inspection
Varies from light to deep brown; from ruddy pink to light pink; from yellow overtones to olive. Color white
Normal
3. Eyeseyeballs
inspection
Dehydrated
Inspection
A healthy adult should be well groomed. The hair is combed while the nails are trimmed.
The client is well groomed. The hair is combed while the nails are trimmed.
Normal
6. Verbal Behavior
Speech should be clear, well paced and coherent. Language should seem appropriate for educational level.
7. NonVerbal Behavior
Facial expression and body movement should be appropriate with the mood and the answers to the questions
Measurements 1. Temperature 2. Pulse Rate 3. Respiratory Rate 4. Blood Pressure 5. Weight 36.5 37.5 C 60 100 bpm 37C 90bpm Normal Normal
12 20 cpm
22 cpm
Elevated
140 / 80 mm Hg
Elevated
95
Body Parts
Norms
Actual Findings
Scalp >> Color, appearance inspection >> Lighter than the color of the face; negative to masses, lumps, lice and dandruff, nits and other depressions >> Negative for >> Lighter than the color of the face; >>presence of dandruff Normal Deviation from normal due to hospitalization
>> Areas of
normal
tenderness
area of tenderness
>> no tenderness
>>Thickness or thinness
Normal
*Nails >>Curvature and angle of the fingernail plate >>Convex curvature; angle of nail plate about 160 degrees >>round nails, about 160 degree nail base Normal
>>Fingernail
Normal
>>Smooth texture
>>Highly vascular and pink in lightskinned clients; dark-skinned clients may have brown or black pigmentation in longitudinal streaks
Normal >>Blanch test >>Nail beds >>Prompt return of return to pink pink or usual color after 3 seconds. (generally less than four seconds)
>>Rounded (normocephalic and symmetrical, with frontal, parietal, and occipital prominences); smooth skull contour
Normal
Normal >>Absence of
depressions >>Smooth uniform consistency; absence of nodules or masses >>Facial features >>Symmetric or slightly asymmetric facial features; palpebral fissures equal in size; symmetric nasolabial folds >>Eyes: edema and hollowness >>Deviation: periorbital edema; sunken eyes >>Symmetry of facial movements (facial nerve)
nodules or masses
*Eye structures and visual acuity >>Eyebrows >>Hair evenly distributed; skin intact >>Eyebrows symmetrically aligned; equal movement >>Evenly distributed, symmetrical movement and alignment Normal
Normal
Normal
>> Blinking
>>Skin intact; no discharge; no discoloration >>Lids close symmetrically >>Approximately 15 to 20 involuntary blinks per minute; bilateral blinking >>When lids open, no visible sclera above corneas, and upper and lower borders of cornea are slightly covered
Normal
>>Bulbar conjunctiva >> Bilateral blinking, involuntary, at approximately 15 blinks/min >>Transparent; capillaries sometimes evident >>Shiny, smooth, and pink or red >>No edema or tenderness over lacrimal gland
>>Palpebral conjunctiva
>>Lacrimal gland
Normal
>>Transparent,
>> No edema
Normal
>>Cornea
shiny, and smooth; details of the iris are visible >> Iris are visible, transparent shiny >>Black in color; equal in size; normally 3-7 mm in diameter; round, smooth border, iris flat and round >>Illuminated pupil constricts (direct response) >>Nonilluminated pupil constricts (consensual response >>Pupil constrict when looking at near vision; pupils dilate when looking at far object; pupils converge when near object is moved toward the nose >>Eyes are coordinated, move in unison, with parallel alignment >>>Able to read newsprint >> unable to read newsprint
Normal
>>Pupil: color, shape, symmetry of size, direct and consensual reaction to light and accommodation
>> Black in color, equal in size >> The pupil constricted when illuminated >> Pupil constricted when looking at near objects and pupils dilate when looking at far object
Deviation from normal due to deterioration of the optic nerves as a result of aging
Normal
bluish hue, in Mediterranean groups and darkskinned clients) >>Soft, moist, smooth texture >>Symmetry of contour Ability to purse lips
or lesions
Normal >>Inner lips and buccal mucosa >>Uniform, pink color (freckled brown pigmentation in dark-skinned clients) >>Moist, smooth, soft, glistening, and elastic texture (drier oral mucosa in elderly due to decreased salivation) >> Dry oral mucosa
>> 18 adult teeth, 2 dental caries >> pink gums >>32 adult teeth >>Smooth, white, shiny tooth enamel >>Pink gums (bluish or dark patches in darkskinned clients) >>Moist, firm texture to gums >>No retraction of gums (pulling away from the teeth)
Normal >>Surface of the tongue >> pink color on tongue borders >>No lesions >> Raised Papillae
>>Pink color (some brown pigmentation on tongue borders in dark-skinned clients); moist; slightly rough; thin whitish coating >>Smooth, lateral margins; no lesions >> Moves freely >>Raised papillae >>Moves freely; no tenderness >> Smooth tongue base >>Smooth tongue base with prominent base >>Base of the tongue, floor of the mouth, and frenulum >>Smooth with no palpable nodules >>Swalowing ability is good, and also tounge >>Swallowing movement and ability, tongue taste. movement, taste >>can identify >> Able to identify any good taste. taste
Normal
Normal
Normal
Normal
Deviation due to
normal >>No deformities >> no deformities >>No tenderness or swelling >> no tenderness and swelling
normal
>>Joints
normal normal
Diagnostic Result: Both lungs are hyper aerated. Heart is not enlarged with atheromatous aorta. Diaphragm and sinuses are intact. There are marginal sclerosis noted at the visualized thoracic vertebrae. Impression: *hyper aerated Lungs *atheromatous Aorta *degenerative Osteoarthric
VIII. Anatomy and Physiology The esophagus is a muscular tube that propels food from the mouth, to the stomach. It begins in the pharynx, just below the base of the tongue, and passes through the chest, next to the spine. It then passes through the diaphragm before emptying into the stomach. The bottom of the esophagus opens during swallowing, and then closes after the food has entered the stomach. This prevents food from leaking back into the esophagus. Anatomy examples: Junction of esophagus and stomach
The esophagus is a tube that makes up part of the digestive tract. It measures about 10 inches long. The esophagus connects the throat with the stomach, carrying the food and liquid you eat from your throat to the stomach. Thats why you often hear it called the food pipe. The esophagus is located behind the windpipe (trachea) and in front of the spine. When you swallow, the esophagus tightens and relaxes, causing waves along the tube. This motion moves food down into the stomach. Glands in the esophagus create mucus to keep the lining moist and to make swallowing easier. The wall of the esophagus has several layers. The innermost coating is called themucosa. Squamous cells are one kind of cell found in the mucosa throughout the esophagus. These cells are normally long and flat. Other cells are glandular oradenoid cells. These cells produce mucus and other fluids. They are found mostly in the stomach but may grow up into the lower part of the esophagus. The lowest end of the esophagus connects to the stomach. This is called thegastroesophageal (GE) junction. Often, this junction is where esophageal adenocarcinoma cancer starts, while squamous cell carcinoma starts anywhere in the esophagus
IX. Pathophysiology
Client will remain free from aspiration, clear lungs, and temperature within normal range for hospital stay.
~Maintain Adequate nutrition through feeding tube, the client is NPO and needs' to get the proper nutrition
~To make sure ~Weigh weekly to that the client is help evaluate client adequately status nutritional nourished.
~Refer client to home infusion healthcare workers Her feeding tube and infusion rates and home
~To ensure she knows how to work to ensure When Adequate nutrition
Assessment Subjective: The Patient verbalized, Simula ng ma confine ako dito sa ospital, hindi na ako nakaka dumi, ang konti kasi ng pinapakain sakin dito sa ospital Objective: -Anorexia -Atypical presentations in older adults.
Planning short term goal: The Client will Establish and regain normal pattern of bowel functioning for 8 hours or until reassessed
Intervention ~Determine fluid intake. ~Instruct and encourage in balances fiber and bulk in diet.
Rationale ~to note deficits. ~to improve consistency of stool and facilitate passage through colon.
Evaluation MET After 8 hours of Nursing Intervention the patient can establish and regain normal pattern of bowel functioning.
~Promote adequate ~to promote fluid intake, moist and soft including high stool. fiber fruit juices; suggest patient to drink warm water, stimulating fluids. ~Encourage activity or exercise within limits of individual ability. ~Administer stool softeners, mild stimulants, or bulk-forming agents as ordered by the Doctor. ~Provide sitz bath after stools. ~to stimulate contractions of the intestines.
d. Health Teachings HOME CARE 1. ANOREXIA Many patients with esophageal cancer will suffer from anorexia. Anorexia means loss of appetite. Anorexia is a problem with many forms ofcancer, because cancer can affect the body's hormones, digestive system and brain. It is also a common side effect of chemotherapy and radiation therapy. Good nutrition is an important part of successful cancer treatment. Adequate nutrition can boost the immune system and help increase the effectiveness ofcancer therapy. Home care for anorexia includes: Avoid stomach irritants such as aspirin or ibuprofen. Avoid excessive caffeine and other stimulants. Check with your doctor about drinking alcohol. Do not force yourself to eat at standard times. Eat when you are hungry instead. Concentrate on eating a healthy diet. Avoid junk foods. Select healthy, high-calorie foods that you enjoy. Eat more frequent, smaller meals. Get some exercise every day. Keep a daily log of your weight. Don't smoke. Nicotine can suppress the appetite. Ask your doctor or nutritionist about dietary supplements. Ask your doctor if any medications you may be taking can cause anorexia. Take any prescribed medications as directed. e. OPD- Out patient Follow Up Keep appointments with the doctor. Remind the client to visit the doctor if she fills anything that concerns about her health. f. Diet Increased Fish Consumption Compared to most meats and poultry, fish is much lower in total fat and saturated fat, is a source of very high-quality protein, supplies lots of vitamins and minerals and contains high levels of omega-3 fatty acids. By adding one or two fish meals to your family's diet each week, you can net some very hefty health benefits.
Plant-Based Nutrition plan a vegan diet that is adequate in protein, calories, vitamins and minerals. Following a vegan diet has been made easier in recent years since vegetarian products fortified with calcium, vitamin D, and vitamin B12 are available in most food stores: vegetarian hot dogs, burgers, fortified soy and rice milks, vegetarian deli slices, and other meat analogs are readily available. Calorie, protein, and all other nutrient needs can be easily met by a vegan diet, supplemented with vitamin B12. Liquid dietThere are two main types of liquid diets: clear liquids and full liquids. Persons who have esophageal cancer may have difficulty swallowing and may require aliquid diet for a period of time. Nutritional supplements are usually necessary in this situation. a. Clear Liquid Diet- Clear liquids are liquids you can see through. Clear liquids can also contain some nutrition, but are usually not adequate to support the body's energy needs for more than a few days. Clear liquids are easily absorbed by the intestines. Liquids remove the stress on the intestines. Clear liquids include: Bouillon soup, Coffee, Broth, Fruit juices without pulp, Gelatin, Tea, and Water b. Full Liquid Diet- This type of diet lies between a solid diet and clear liquids. It is often used by someone who is tolerating clear liquids, but cannot tolerate solid food. A full liquid diet can safely sustain the body for long periods of time. Full liquids include: Cream of wheat, Fruit juices, Honey, Jelly, Milk, milkshakes and ice cream.Nutrition supplement drinks, such as Ensure or Boost, Pureed meats, Pureed vegetables, Soups without solids, Syrups, Vegetable juices, Yogurt and pudding. b. Safety Observe for signs and symptoms of complications. Ready your self for all the procedure you will undergo.