Adenocarcinoma,

Moderately Differentiated

Introduction
Moderately differentiated adenocarcinoma is made
up of cells that, for the most part, resemble normal,
healthy cells. These cells have some malformations in
their components and may divide at an increased rate but
are not considered to be as aggressive as cells that are
poorly differentiated. The prognosis for cancers with
moderately differentiated cells depends on a number of
factors, such as the organ or system affected by the
cancer, the size of the tumor and how widespread the
cancer is, but it is generally better than the prognosis
given when patients have poorly differentiated cancer
cells.

Rectal cancer is common but occurs very rarely in

young adults. Rectal cancer becomes more common as
age increases. People in their 50s, 60s and 70s are
most at risk with sex incidence being more common
in females. Geographically, the rectal cancer tumor is
found worldwide, but rectal cancer is most common
in areas which have low fiber diets. Areas of the world
with high fat consumption and low fiber consumption
such as Europe, USA and Australia.

Furthermore, in the Philippines, 75% of all cancers occur

after age 50 years, and only about 3% occur at age 14
years and below. If the current low cancer prevention
consciousness persists, it is estimated that for every 1800
Filipinos, one will develop cancer annually. At present,
most Filipino cancer patients seek medical advice only
when symptomatic or at advanced stages: for every two
new cancer cases diagnosed annually, one will die within
the year. It is estimated that 3050% of cancer patients in
all stages of the disease will experience pain and 7095%
with advanced disease will have significant pain, but only a
fraction of these patients receive adequate treatment.

Patient G, 60 years old female, a resident of

Nagpandayan, Guimba, Nueva Ecija was admitted at
Dr. Paulino J. Garcia Memorial Research and Medical
Center for complaints of severe pain in the anorectal
area associated with bloody stool on August 08, 2014
at 11:24 am.

The lack of knowledge and information about

Adenocarcinoma, Moderately Differentiated is one of the
reasons why we chose this case. Not many Filipino women
know about the disease, that it is preventable and can be
cured when detected at the onset. We strongly believe that
this case study will be very helpful in our career someday
as future registered nurses. And also we want to improve
our knowledge in studying cancer, because of our subject
oncology.

Learning Goal
Skills

Student Centered
Client Centered
To be able to perform the To be able to perform
nursing skills learned in school
Independent nursing skills
into real life situation such as
such
as
providing
Providing
safety
and
comfort,
maintaining
maintaining privacy
privacy, monitoring, and
Proper
vital
signs
keeping the safety of the
monitoring
patient.
Giving holistic care and
other necessary nursing
interventions needed for the
patient.
Triaging patients properly
in giving care
Admission care in the E.R.
Taking ECG.
Placing indwelling foley
catheter
Nebulizing and suctioning

Knowledge

To be able to acquire knowledge To impart necessary health teachings

regarding
adenocarcinoma to the patient and explain her disease
moderately differentiated, its based on her level of understanding.
signs
and
symptoms,
pathophysiology and course of
treatment.
Familiarity
with
common
emergencies and patient concerns
that cause them to seek care.
To be able to know the possible
prevention
and
proper
management of adenocarcinoma
moderately differentiated.

Attitude

To be able to behave in front of To be able to encourage patient to

the patient in a therapeutic accept her disease and act accordingly
manner.
with her current condition.
To be able to act professionally
with the supervision of our
clinical instructor.

Bioprofile/Presonal Data:

Name: Patient G
Age: 60 years old
Sex: Female
Birthdate: August 12, 1953
Birthplace: Nagpandayan, Guimba, Nueva Ecija
Marital Status: Married
Address: Nagpandayan, Guimba, Nueva Ecija
Occupation: Housewife
Religion: Roman Catholic
Date and time of consultation: August 08, 2014 at 11:24 AM
Attending Physician: Dr. Salamanca

Chief Complaint:
The patient experienced pain in the anorectal area
associated with bloody stool 2 days PTC.

History of Present Illness:

Two (2) days prior to consultation the patient noted
pain during defecation associated with some bleeding
and changes in the character of stool. She did not
went to hospital immediately because she thought that
the bleeding will stop if she will take the medicine the
doctor gave her during her consultation last April 14,
2014 in Premiere Medical Center. But 2 days have
passed the bleeding didnt stop, so she decided to go
in Dr. Paulino J. Garcia Memorial Research and
Medical Center to seek medical help.

Past Medical History:

Last April 14, 2014 Patient G. went to Premiere
Medical Center to seek consultation because she s
experiencing bloody stool and pain while defecating
one day after she ate a lot of spicy foods. Her guaiac
stool examination revealed that her stool has plenty of
bacteria and her doctor gave her a prescription of
medications. On the same day that day she had
undergone anoscopy with biopsy and was diagnosed
moderately differentiated adenocarcinoma and is
malignant.

Past Surgical History:

The patient has not undergone any surgery.

Allergies/ Medications:
She claimed that she has no allergies to any foods and
medications. The following are the medications shes
taking before consultation:
Metronidazole 500mg
Omeprazole 20mg
Maalox 200mg
Tranexamic Acid 500mg

Smoking, Alcohol, Substance

Abuse :
She claimed that she is not a smoker, she doesnt
drink alcohol and is not involve in taking any
prohibited drugs.

Social/ Work History:

The patient is a married housewife.

Family History:
Upon taking the interview, Patient G. has a family
history of colon cancer on her brother and sister
which are now dead. Her mother has ulcer and goiter
and her father has chronic bronchitis.

Review Of System:

Pathophysiology

MODIFIABLE FACTORS
Lifestyle
Diet
Low-socioeconomic status

NON-MODIFIABLE FACTORS
Gender (female)
Age (60 y/o)
Genetics

Alteration in the normal cell

Proto-oncogenes transform to oncogenes

Tumor suppressor genes are turned off

Quick abnormal cell growth and division

DNA repair genes is inactivated
Increases survival and proliferation of cancer cells

Spreads out from the colon

Invades epithelium of the bowel
Mucosa in the large intestine regenerates

Crypt cells migrate from the base to the surface

Undergoes differentiation and maturation
Loss of proliferation control
Formation of malignant tumor in epithelial tissue
(ADENOCARCINOMA)

Proliferates to anus
Anoscopy
with biopsy
done
Ulcerating mass
Loss of blood

Affects rectum creating ano-rectal mass

Rectal obstruction
Hematochezia
Pain

Increase BP, RR, HR

Pallor
Body weakness
Decrease of hemoglobin & hematocrit

Compression of
urinary bladder
Urine retention
Oliguria

Physical Assessment:
I. Vital Signs
Temperature
Pulse Rate
Respiratory Rate
Blood Pressure

Actual Findings
37.1 degree Celsius
110 beats per minute
28 cycles per minute
130/90 mmHg

II. Level of Consciousness

Conscious and Coherent

III. BODY PARTS

NORMAL FINDINGS

GENERAL APPEARANCE

With normal weight, Thin in appearance. Her thin in appearance is due

afebrile, proportionality Afebrile,
to her aging in which there is a
The body parts are decreased in the distribution of
and symmetry
proportional to each fats within the body. Her
disease also contributes in his
other.
thin appearance.
The color depends on Pallor noted.
Due to blood loss.
race, ethnic background, Cool and clammy to touch.
complexion, sun exposure, Good skin turgor in both
and
pigmentation
upper and lower extremities;
tendencies.

SKIN

EYES and VISION

Normal vision of 20/20,

ACTUAL FINDINGS

Pale conjunctiva.

REMARKS

Pale conjunctiva is due to blood

loss.

(+) Pupils Equal Round and

Reactive
to
Light
Accommodation
(PERRLA).

MOUTH

Lips are moist and Dry and pale lips noted Due to blood loss.
pink, no masses, gums upon inspection.
are pink and smooth,
The tongue is midline
and
without
any
hoarseness of voice.

A. HEART

No palpitations, normal Rapid pulse rate (110 Due to the

PR should be 60- 100 in beats per minute)
experiencing
adult

pain

shes

A. ABDOMEN

The contour of the Abdominal pain (pain Due to the presence of anoabdomen is usually flat scale
of
7/10) rectal and ulcerating mass.
and rounded, the skin complained.
surface is smooth, and
even with homogenous
color and good skin
turgor.

DRUG STUDY

NAME OF
DRUG

ORDERED
DOSE

MECHANISM OF
ACTOIN
INDICATION

CONTRAINDICATION

Metronidazole

500 mg

Is
a nitroimidazole a
ntibiotic medicatio
n used particularly
for anaerobic bact
eria and protozoa.
It
is antibacterial ag
ainst
anaerobic
organisms,
an
amoebicide,
and
an antiprotozoal

Allergy to drug

liver disease;

a stomach or
intestinal
disease such as
Crohn's
disease;
a blood cell
disorder such
as anemia (lack
of red blood
cells)
or
leukopenia
(lack of white
blood cells);
epilepsy
or
other
seizure
disorder; or
nerve
disorders.

Metronidazole
is used to treat
bacterial
infections of the
vagina,
stomach, skin,
joints,
and
respiratory
tract.

SIDE EFFECTS NURSING

&ADVERSE
RESPONSIBILITY
REACTONS

numbness
Administer with
or tingling
food or milk to
in
your
GI
hands
or minimize
irritation.
Tablets
feet;

pain
or may be crushed for
burning
patients
with
when you
difficulty
urinate;
swallowing.

diarrhea
that
is Instruct patient to
watery or
take
medication
bloody;
exactly as directed

vision
evenly spaced times
problems,
pain behind between dose, even if
your eyes;
feeling better. Do not

fever, chills,
skip doses or double
muscle
up on missed doses.
pain,
confusion,
If a dose is missed,
headache,
take as soon as
sore throat,
remembered if not
neck
stiffness,
almost time for next
increased
dose.
sensitivity
May cause dizziness
to
light,
drowsiness, or light-headedness.
nausea and Caution patient or
vomiting; or other
activities
requiring alertness
until response to
medication is known.

NAME OF
DRUG

ORDERED
DOSE

MECHANISM OF
ACTOIN
INDICATION

CONTRAINDICATION

SIDE EFFECTS NURSING

&ADVERSE
RESPONSIBILITY
REACTONS
Less serious
metronidazole
side effects may
include:

stomach
pain,
diarrhea;

dizziness,
loss of
balance;

vaginal
itching or
discharge;

cough,
sneezing,
runny or
stuffy nose;
or

swollen or
sore
tongue.

Inform patient that

medication may
cause an unpleasant
metallic taste.
Inform patient that
medication may
cause urine to turn
dark.
Advise patient to
consult health care
professional if no
improvement in a
few days or if signs
and symptoms of
superinfection (black
furry overgrowth on
tongue; loose or foulsmelling stools
develop).

NAME OF
DRUG

ORDERED
DOSE

MECHANISM OF
ACTOIN
INDICATION

CONTRAINDICATION

SIDE EFFECTS NURSING

&ADVERSE
RESPONSIBILITY
REACTONS

Omeprazole

20 mg

Omeprazole
belongs to group
of drugs called
proton
pump
inhibitors.
It
decreases
the
amount of acid
produced in the
stomach.
Omeprazole
is
used
to
treat
symptoms
of
gastroesophageal
reflux
disease
(GERD) and other
conditions caused
by excess stomach
acid. It is not for
immediate relief of
heartburn
symptoms.
Omeprazole is also
used to promote
healing of erosive
esophagitis
(damage to your
esophagus caused
by stomach acid).

Atrophic Gastritis,
Liver
Problems,
Clostridium Difficile
Bacteria
Related
Colitis, Osteoporosis,
Broken Bone, Low
Amount
of
Magnesium in the
Blood
Allergies:
PROTON
PUMP
INHIBITORS

Omeprazole can
be used in the
treatment
of gastroesopha
geal
reflux
disease, peptic
ulcers, erosive
esophagitis

nausea
vomiting
headache
rash
dizziness

Tell patient to take

drug before eating
(before
breakfast)
and
to
swallow
capsules whole.
Tell the patient to
drink a glass of cool
water.
Encourage patient to
avoid
alcohol,
aspirin
products,
ibuprofen, and foods
that may increase
gastric
secretions
during therapy.
Advise patient to
notify
doctor
immediately if they
have abdominal pain
or diarrhea.

NAME OF
DRUG

ORDERED
DOSE

MECHANISM OF
ACTOIN
INDICATION

CONTRAINDICATION

SIDE EFFECTS NURSING

&ADVERSE
RESPONSIBILITY
REACTONS

Maalox

200 mg

This
medication
works only on
existing acid in the
stomach. It does
not prevent acid
production. It may
be used alone or
with
other
medications that
lower
acid
production (e.g.,
H2 blockers such
as cimetidine/ranit
idine and proton
pump inhibitors
such
as omeprazole).

Constipation;
diarrhea.Severe
allergic
reactions
(rash; hives; itching;
difficulty breathing;
tightness
in
the
chest; swelling of the
mouth, face, lips, or
tongue);
loss
of
appetite;
muscle
weakness; nausea;
slow
reflexes;
vomiting.

Maalox
generally
doesnt produce
serious side
effects in
individuals who
use it for less
than two weeks,
but some mild
side effects may
appear. Possible
side effects of
Maalox
include nausea,
diarrhea,
constipation,
and headaches.

Treating
acid
indigestion,
heartburn, and
sour stomach.

Give 1 hr after
meals.
Avoid
giving
medications within
1-2 hrs of antacid
administration
(decreases
absorption).
- Take fluids to flush
after
intake
of
antacid suspensions.
Monitor
for
changes of bowel
patterns.

NAME OF
DRUG

ORDERED
DOSE

MECHANISM OF
ACTOIN
INDICATION

CONTRAINDICATION

Tranexamic
acid

500mg

Tranexamic acid is
a
synthetic
derivative of the
amino acid lysine.
It
exerts
its
antifibrinolytic
effect through the
reversible
blockade of lysinebinding sites on
plasminogen
molecules.

Allergic reaction to Severe allergic

the
drug
or reactions such
hypersensitivity
as rash, hives,
itching,
Presence of blood dyspnea,
clots (eg, in the leg, tightness in the
lung, eye, brain), chest, swelling
have a history of of the mouth,
blood clots, or are at face, lips or
risk for blood clots
tongue

Tranexamic
acid is used for
the prompt and
effective control
of hemorrhage
in
various
surgical
and
clinical areas:
Treating heavy
menstrual
bleeding
Hemorrhage
following dental
and/or
oral
surgery
in
patients
with
hemophilia

Current
administration
of
factor IX complex
concentrates or antiinhibitor coagulant
concentrates

SIDE EFFECTS NURSING

&ADVERSE
RESPONSIBILITY
REACTONS

Chest pain
Confusion
Coughing
up
blood
Decreased
urination
Severe
or
persistent
headache
Severe
or
persistent body
malaise
Shortness
of
breath
Slurred speech
Slurred speech
Vision changes

Unusual change in
bleeding
pattern
should
be
immediately
reported
to
the
physician.
For
women
the
medication
should
only be taken during
the menstrual period
for heavy bleeding.
Tranexamic
Acid
should be used with
extreme caution in
CHILDREN
younger than 18
years old; safety and
effectiveness in these
children have not
been confirmed.

The medication can

be taken with or
without meals.

NAME OF
DRUG

ORDERED
DOSE

MECHANISM OF
ACTOIN
INDICATION
Surgical:
General
surgical
cases
but
most
especially
operative
procedures on
the
prostate,
uterus, thyroid,
lungs,
heart,
ovaries,
adrenals,
kidneys, brain,
tonsils, lymph
nodes and soft
tissues.
Medical:
epistaxis,
hemoptysis,
hematuria, pept
ic ulcer with
hemorrhage and
blood dyscrasias
with
hemorrhage

CONTRAINDICATION

SIDE EFFECTS NURSING

&ADVERSE
RESPONSIBILITY
REACTONS
Swallow Tranexamic
Acid whole with
plenty of liquids. Do
not break, crush, or
chew
before
swallowing.
Inform the client
that he/she should
inform the physician
immediately if the
following severe side
effects occur.

Laboratory results
Laboratory

Normal Value

CHEST X-RAY

Normal size and shapes of the chest

wall.

CBC

URINALYSIS

ANOSCOPY with
BIOPSY

Result

Interpretation

(-) congestion

Normal

(+) pleural
thickening, right

Possible underlying
lung condition

Hematocrit

0.37-0.48

0.30

Due to blood loss

Hemoglobin

7.4-9.9 mmol/L

6.2 mmol/L

Due to blood loss

WBC

4.5-10.5

11.2

Presence of infection

(+) pus 1-2

Presence of infection

(+) RBC 1-2

Presence of infection

Adenocarcinoma,
Moderately
Differentiated

With cancer

No pus and RBC present.

Normal anorectal area

Course in E.R.
DATE
08-08-2014

INTERVENTIONS
Admitted a 60 year old female patient to FSW under yellow
team.
Secure consent of admission.
Monitor vital signs and record.
CBC, APC, BUN, CREA, FBS, BT, PTT done.
ECG done.
IVF of D5LRS 1L for 24Hours
Referred.

Nursing Care Plan

ASSESSMENT

NURSING
DIAGNOSIS

Subjective:
Deficient
fluid
May dugo ang volume related to
dumi
ko
as active fluid loss
verbalized by the due
to
patient.
gastrointestinal
bleeding
as
Objective:
evidenced
by
Patient
appears presence of blood
weak
and in stool.
lethargic, pale, lips
are dry and pale,
slow
capillary
refill, skin is cold,
dry with poor skin
turgor, Palms and
sole of feet is pale.
Blood in stool (2
diapers per day)

Vital signs taken

as follows:
BP:120/80
T:37.1
RR:19
PR:78
HGB: 6.2
HCT: 0.30

INFERENCE

PLANNING

Formation of
malignant tumor
in epithelial
tissue
(ADENOCARCINO
MA)

After 8 hours of
nursing
intervention the
patient will be
able to exhibit
relevant normal
levels
of
laboratory value
such
as
in
hemoglobin and
red blood cell
level

Proliferates to
anus

Affects rectum
creating anorectal mass

Ulcerating mass,
Rectal
obstruction

Hematochezia

INTERVENTI
ON

RATIONALE

Assess
patient To
know
general condition condition
of
and
establish patient and to
rapport
gain trust and
cooperation from
the client

EVALUATION

After 8 hours of
nursing
intervention the
patient had to
Exhibited
relevant normal
levels
of
Assess vital signs To
gather laboratory value
baseline data
such
as
in
hemoglobin and
Raise
bedside To provide safety red blood cell
rails
level
Note patients
Worsening
of
individual
symptoms
may
physiological
reflect continued
response
to bleeding
or
bleeding
inadequate fluid
replacement.

Monitor intake
and
output
(I&O),
and
correlate
with
weight changes.

Provides
guidelines
for
fluid
replacement.

ASSESSMENT

NURSING
DIAGNOSIS

INFERENCE

PLANNING

INTERVENTI
ON

RATIONALE

Monitor intake
and
output
(I&O),
and
correlate
with
weight changes.

EVALUATION

Provides
After 8 hours of
guidelines
for nursing
fluid
intervention the
replacement.
patient had to
Exhibited
relevant normal
Maintain
bed Activity/vomiting levels
of
rest;
prevent increases intra- laboratory value
vomiting
and abdominal
such
as
in
straining at stool. pressure and can hemoglobin and
lead to further red blood cell
bleeding.
level
Provide
clear/bland fluids
when intake is
resumed. Avoid
caffeinated and
carbonated
beverages

Caffeine
and
carbonated
beverages
stimulate
hydrochloric acid
(HCl) production,
possibly
potentiating
rebleeding.

Facilitate
in
blood transfusion
Administer
medications, as
indicated

Transfused
all
blood
components that
are low in the
laboratory
results.

ASSESSMENT

NURSING
DIAGNOSIS

INFERENCE

Subjective:
Nahihirapan ako,
Masakit kasi yung
tiyan
ko
as
verbalized by the
patient

Acute
pain
related to tissue
compression and
obstruction
secondary
to
colon cancer as
manifested
by
patients
grimacing when
in pain, pain scale
of 7/10.

Formation of
malignant tumor
in epithelial
tissue
(ADENOCARCINO
MA)

Pain scale: 7/10

Objective:

Proliferates to
anus

Limited
movement noted
Grimace when in
pain
Guarding behavior
noted
Vital signs taken
as follows:
BP:130/90
T:36.9
RR:20
PR:89

Affects rectum
creating anorectal mass

Ulcerating mass,
Rectal
obstruction

PLANNING

INTERVENTI
ON

RATIONALE

After 8 hours of Assessed

for helps determine
rendering
referred pain
possibility
of
effective nursing
underlying
interventions the
condition
clients
Observed
and Observations
pain is relieved
noted non verbal may be congruent
cues and pain with
verbal
behavior
reports or may be
only
indicator
present
when
client
cant express
feelings.
Assessed intensity
and
characteristics of
pain

to rule out degree

and type of pain
experienced by
client

Provided comfort to promote nonmeasures such as pharmacological

positioning and pain management
back rubbing

Pain

Assisted
and
educated client
on
relaxation
techniques such

Techniques are
used to bring
about a state of
physical
and
mental awareness

EVALUATION

Goal
partially
met as the client
showed
cooperation
on
therapeutic
nursing
interventions and
the
patient
verbalized that
pain felt was
relieved.

ASSESSMENT

NURSING
DIAGNOSIS

INFERENCE

PLANNING

INTERVENTI
ON

RATIONALE

as
breathing and tranquillity.
exercises.
. The goal of
these techniques
is
to
reduce
tension,
subsequently
reducing pain

EVALUATION

Goal
partially
met as the client
showed
cooperation
on
therapeutic
nursing
interventions and
the
patient
verbalized that
pain felt was
relieved.

ASSESSMENT

Subjective:

Nanghihina
ako,
pakiramdam ko lagi
akong pagod.
(I feel very tired and
weak)
as verbalized by the
patient.
Pain scale: 7/10

HGB: 6.2
HCT: 0.30

PLANNING

INTERVENTI
ON

RATIONALE

EVALUATION

Fatigue related to
altered
body
chemistry
and
side effects of
pain
as
manifested
by
decreased
hemoglobin and
hematocrit count
and pain scale of
7/10.

Formation of
malignant tumor
in epithelial
tissue
(ADENOCARCINO
MA)

After 8 hours of
nursing
interventions, the
patient
will
report improved
sense of energy.

Have patient rate

fatigue, using a
numeric scale, if
possible, the time
of day when it is
most severe.

Help
in
developing a plan
for
managing
fatigue

After 8 hours of
nursing
interventions, the
patient was able
to
report
improved sense of
energy.

Assist
patient
with
self-care
needs. Keep bed
in low position
and assist with
ambulation

Weakness
may
make activities of
daily living and
ambulation
difficult, further
assistance
is
needed.

Encourage
patient to do
whatever possible
and
increase
activity level as
tolerated.

Enhances
strength
and
enables patient to
become
more
active
without
undue fatigue.

Perform
assessment
provide

Poorly managed
cancer pain can
contribute
to
fatigue.

Proliferates to
anus

the

as

Ulcerating mass,
Rectal
obstruction

Lethargy
V/S
taken
follows:
T: 37.3
P: 90
R: 22
BP: 110/90

INFERENCE

Affects rectum
creating anorectal mass

Objective:
Disinterest in
surrounding.

NURSING
DIAGNOSIS

Loss of blood

Body weakness,
Decrease in hct
and hgb

pain
and
pain
management
as
prescribed.

Discharge Planning
Medications
Advice patient to continue taking medications needed to maintain a
normal functioning of the body and maintain homeostasis. The
treatment regimen ordered by the doctors must be followed strictly
and should not be stopped to prevent the aggravation of the
condition. The full course of antibiotics should be followed.
Advice the patient to observe the any reaction towards the given
medications and signs that needs to call the attention of the
physician.

 Exercise
Encourage patient to have an active and passive ROM because it will
promote blood circulation and to improve muscle strength in order
to promote total range of motion.

Treatment:
Instruct patient to consult the physician first if what activities must
he/she avoid or put into limits.
Encourage patient to compliance of medication regimen to promote
optimal health.

 Health Teachings:
Importance of personal hygiene to prevent infection.
Intake of nutritious foods like vegetables and fruits and intake of
foods that is rich in fiber such as green leafy vegetables and
pineapple, also increased fluid intake to prevent constipation.
Strict compliance of medication regimen to promote wellness.
Immediate report to the physician if unusual occurrences occur.

 Out-Patient:
Return to OPD for further check-up if whether it is
improving or not. Also, for early diagnosis of any other
underlying conditions.

Diet:
Encourage client to eat nutritious or healthy foods such as fruits and
vegetables and foods that are high in fiber such as green leafy
vegetables, wheat, cereal and pineapple. Suggest client also to consult
to a dietary physician to know what the correct dietary intake he
must maintain are.

FIN.