Case Study-gastric Cancer

CASESTUDY IN GASTRIC ULCER

SUMITTED BY:

DEVIE MARIE AGUSTIN SHERYL CABELIZA MABEL DEL ROSARIO REGINA MARIE GRANDE RIA LUCY QUERAL BLENDINA TEMPORAL

SUBMITTED TO: MR. JAKE B. CANAPI

CLIENTS PROFILE

Name:

C.Z

Age:

71 y/o

Gender:

Female

Address:

Maluyo, Allacapan Cagayan

Birthday:

October 25, 1939

Religion:

Iglesia Ni Cristo

Occupation:

Housekeeping

Admission date:

September 30, 2011

Time:

1: 25 a.m.

Chief complaints:

abdominal pain

Admitting Diagnosis:

Gastric Cancer

Admitting Physician:

Dr. Tiangco

NURSING HEALTH HISTORY Present health history One day PTA, the patient complain abdominal Pain of her RUQ, hence admitted to CVMC. Past health history 6 months PTa,patient complain of severe abdominal pain at the RUQ,patient was noted to tondo hospital and one medical intervention done was bloob transfusion,1 day PTA, patient with the recurrence of the condition patient was brought to CVMC.She also have no vaccination at all. Social health history According to the patient she is a housewife and a smoker.she has a 11siblings but 9 are still alive,5 boys and 4 girls ,their house is made of wood with 2 rooms and 3 windows,they have an animals like chicken,pig and duck.they poultry is near their house and for their drinking water is purified. Family history According to t he patient ,she has a history of brain cancer with her father side

ANATOMY AND PHYSIOLOGY

INTRODUCTION Gastric cancer was once the second most common cancer in the world. In most developed countries, however, rates of stomach cancer have declined dramatically over the past half century. In the United States, stomach malignancy is currently the 14th most common cancer. Decreases in gastric cancer have been attributed in part to widespread use of refrigeration, which has had several beneficial effects: increased consumption of fresh fruits and vegetables; decreased intake of salt, which had been used as a food preservative; and decreased contamination of food by carcinogenic compounds arising from the decay of unrefrigerated meat products. Salt and salted foods may damage the gastric mucosa, leading to inflammation and an associated increase in DNA synthesis and cell proliferation. Other factors likely contributing to the decline in stomach cancer rates include lower rates of chronic Helicobacter pylori infection, thanks to improved sanitation and use of antibiotics, and increased screening in some countries. Nevertheless, gastric cancer is still the second most common cause of cancer-related death in the world, and it remains difficult to cure in Western countries, primarily because most patients present with advanced disease. Even patients who present in the most favorable condition and who undergo curative surgical resection often die of recurrent disease. However, 2 studies have demonstrated improved survival with adjuvant therapy: a US study using postoperative chemoradiation and a European study using preoperative and postoperative chemotherapy. Anatomy The molecular biology responsible for carcinogenesis, tumor biology, and response to therapy in stomach cancer are active areas of investigation but are not addressed in this review. Instead, this article focuses on clinical management, which first requires a thorough understanding of gastric anatomy. An image depicting stomach anatomy can be seen below.

Stomach and duodenum, coronal section. The stomach begins at the gastroesophageal junction and ends at the duodenum. The stomach has 3 parts: the uppermost part is the cardia; the middle and largest part is the body, or fundus; and the distal portion, the pylorus, connects to the duodenum. These anatomic zones have distinct histologic features. The cardia contains predominantly mucin-secreting cells. The fundus contains mucoid cells, chief cells, and parietal cells. The pylorus is composed of mucusproducing cells and endocrine cells. The stomach wall is made up of 5 layers. From the lumen out, the layers include the mucosa, the submucosa, the muscularis layer, the subserosal layer, and the serosal layer. The peritoneum of the greater sac covers the anterior surface of the stomach. A portion of the lesser sac drapes posteriorly over the stomach. The gastroesophageal junction has limited or no serosal covering. The right portion of the anterior gastric surface is adjacent to the left lobe of the liver and the anterior abdominal wall. The left portion of the stomach is adjacent to the spleen, the left adrenal gland, the superior portion of the left kidney, the ventral portion of the pancreas, and the transverse colon. The site of stomach cancer is classified on the basis of its relationship to the long axis of the stomach. Approximately 40% of cancers develop in the lower part, 40% in the middle part, and 15% in the upper part; 10% involve more than one part of the organ. Most of the decrease in gastric cancer incidence and mortality in the United States has involved cancer in the lower part

of the stomach; the incidence of adenocarcinoma in the cardia has actually shown a gradual increase. Pathophysiology There are 3 oncogenic pathways that are deregulated in the majority (>70%) of gastric cancers: the proliferation/stem cell, NF-kappa β, and Wnt/beta-catenin pathways. Their study suggests that interactions between these pathways may play an important role in influencing disease behavior and patient survival. Understanding the vascular supply of the stomach allows understanding of the routes of hematogenous spread. The vascular supply of the stomach is derived from the celiac artery. The left gastric artery, a branch of the celiac artery, supplies the upper right portion of the stomach. The common hepatic artery branches into the right gastric artery, which supplies the lower portion of the stomach, and the right gastroepiploic branch, which supplies the lower portion of the greater curvature. Understanding the lymphatic drainage can clarify the areas at risk for nodal involvement by cancer. The lymphatic drainage of the stomach is complex. Primary lymphatic drainage is along the celiac axis. Minor drainage occurs along the splenic hilum, suprapancreatic nodal groups, porta hepatis, and gastroduodenal areas.

GORDON’S 11 FUNCTIONAL HEALTH PATTERN

HEALTH PERCEPTION-HEALTH MANAGEMENT PATTERN Before hospitalization: The patient views health as an important matter. She said that absence of disease means wellness which is contributive to her satisfying performance of ADL’ s. She believes in doctors and nurses but takes OTC meds except ibuprofen because according to her she has allergy on it. During Hospitalization The patient and her SO’s acquired help from the hospital when she experience pain on her abdomen. She was admitted because they believed that her condition is a serious matter.

NUTRITIONAL METABOLIC PATTERN Before hospitalization The patient has no allergy on food. She usually eats 3x a day but sometimes losses her appetite. Her usual meals is composed of coffee, rice, while her lunch and dinner composed of rice, vegetables , meat or fish. She drink 5-6 glasses a day. During Hospitalization The patient is NPO for 2 days prior to her operation. ELIMINATION PATTERN Before Hospitalization The patient has irregular bowel function. she sometimes defecate once or twice a week and sometimes she defecates everyday with a dark brown stool. She urinates 5-6 times a day with a yellow ambered urine. During Hospitalization The patient was on IFC intact and draining well. She had a dark yellow orange urine. She did not yet defecate. SLEEP REST PATTERN Before Hospitalization According to the patient, she has trouble in sleeping. She sleeps 10 in the evening and wakes up 1 in the morning. Then if she feels sleepy in the morning even if she was doing her household chores she goes to bed and sleeps. She doesn’t take naps in the afternoon .She only sits and stays at home and sometimes she watch TV.

During Hospitalization . According to her, she cannot sleep well due to the pain she feels. She usually get her sleep at 8 in the evening but wakes at 10 then she gets her sleep at 1 and wakes up at 5 am. ACTIVITY EXERCISE PATTERN Before Hospitalization The patient considers he daily household chores to be a form of her exercisers. She cleans the house, washed the clothes, and washed the dishes. During Hospitalization

The patient almost stays on her bed lying flat. According to her she cannot do bathing alone. She needs assistance of her grandson and his husband in going to the C.R

COGNITIVE PERCEPTUAL PATTERN Before Hospitalization The client is in good mental status. She just finish grade 2. She knows a little in reading and writing .She can understand tagalog, ilokano and itawis. She knows how to compute. During hospitalization The client has a good communication skills. She interacts with us actively and happily .She answers our question immediately and comprehensively. But she is not aware of her disease she only that she has a serious disease and needs a prompt treatment.

ROLE-RELATIONSHIP PATTERN Before hospitalization According to the patient, she lives with her husband and stays their daughter at Allacapan Cagayan. She has 2 children but only one are alive. She has 17 grandsons and granddaughters. They have a good relationship with each other. They sometimes have misunderstanding but they settle it immediately. During hospitalization Her husband and her grandson are there to care for her. They are very supportive and they provide all her needs in her hospitalization SELF PERCEPTION-SELF CONCEPT PATTERN Before Hospitalization She considers herself as a strong person and she do her best to provide the needs of their family. She considers herself as helpful especially in doing their household chores. She often socialized with her neighbors but she was friendly and accommodating when neighbors came to their house .She was a loving parent as well as being a grandmother to her grandsons and granddaughters. During Hospitalization She considers herself as a burden to her family due to her condition. But she still believes that she can still help her family by helping herself to recover from her illness. COPING-STRESS TOLERANCE PATTERN Before Hospitalization According to the patient, dirty house, quarrels and noisy environment predispose her mostly to stress. When she encounters problems she solve it herself. As much as possible, she doesn’t want to tell it to her family. But if he can no longer bear it, she tells it to her husband, and her children. During Hospitalization She feels stress all the time because of her condition. But she was able to manage it by talking to her husband and taking rest.

SEXUALITY-REPRODUCTIVE PATTERN

Before Hospitalization According to the patient, she had her menarche when she was 12 years old and menopause at the age of 40. She was married when she was 17 years old. She has 11 children, 5 boys and 6 girls, 2 are now dead due to rabies and unknown disease. Her children were all married and she had also 17 grandchildren. During hospitalization According to the patient, she can no longer engage in sexual activity because they are too old enough to do it. VALUES- BELIEF PATTERN Before Hospitalization She was an active member as well as a deaconess of the Iglesia ni cristo since 1982 . she attends mass every Thursday and Saturday . She has a strong faith in God and she considers as a powerful instrument on her daily life. During Hospitalization The clients faith was still very strong even if she has illness. She hopes that through the help of God, she will get soon. She always pray and trust God that He will be there for her. She entrusted her life to God.

PHYSICAL ASSESSMENT AREA ASSESSED SKIN  Color

 Temperature

 Mobility and turgor HAIR  Color  Texture  Distribution

METHOD USED NORMAL FINDINGS

ACTUAL FINDINGS

REMARKS

Inspection

Varies from light to deep brown, from ruddy pink to light pink, from yellow overtone to olive.

With pallor

Slightly Normal

Palpation

Uniformity of warmth and within the normal range Varies with environmental temp. And humidity, body temp. And activity.

37.1

Normal

Varies with environmental temp. and humidity, body temp. and activity.

Normal

Palpation

Springs back to normal when pinched.

Thin legs and feet.

Normal

Inspection Palpation inspection

Black Fine, straight, silky and resilient Evenly distributed hair

Black Fine but dry Evenly distributed hair

Normal Normal Normal

Nail surface is slightly curved or flat Nail edges are smooth, rounded and clean Pink, highly vascularized Prompt return of usual color(1sec.)

Surface is slightly curved Edges are rough and dirty Yellowish-whitish Prompt return of usual color

Normal Due to poor hygiene Normal Normal

Normocephalic and symmetrical facial movement

Normocephalic and symmetrical facial movement

Normal

NAIL  Shape and contour inspection  Color Inspection  Blanch test palpation

Head  Size and shape

Inspection

 Facial structures

Inspection

No abnormalities in structure, no involuntary muscle movement in facial muscles

No abnormalities in structure, no involuntary muscle movement in facial muscles

Normal

EYES  Eyebrows

Inspection

Inspection

Hair evenly distributed, skin intact Symmetrically aligned, equal movement Equally distributed, curved slightly outward Clear, no discharge

Normal

 Eyelashes

Hair evenly distributed, skin intact Symmetrically aligned, equal movement Equally distributed, curved slightly outward Clear, no discharge

 Eyelids

Inspection

PERRLA

PERRLA

Normal

 Conjunctiva

Inspection

Clear and unicteric

Clear and unicteric

Normal

 Pupil

Inspection

Normal

inspection

Normal

 Sclera NOSE  Size, shape and color  Discharge  Nares  Septum MOUTH  Lips

Inspection Inspection Inspection

Normal

Symmetric and straight, color brown same as facial color No discharge No nasal flaring Intact and in midline

Symmetric and straight, color red No discharge No nasal flaring Intact and in midline

Pink color, soft, moist, smooth

Dry lips

Due to possible dehydration

 Teeth

Inspection and palpation Inspection

Smooth, white, shiny tooth enamel

Normal

 Gums

Inspection

Pink gums, moist, firm in texture

Smooth, yellowish enamel, incomplete teeth Pink gums, moist, firm in texture

Inspection

Normal Normal Normal Normal

Normal

NECK  Head movement TH0RAX AND LUNGS  Posterior and anterior thorax  Lungs ABDOMEN  symmetry umbilicus  tenderness EXTREMITIES  upper

 lower

Inspection

Coordinated smooth movements without discomfort

Coordinated smooth movements without discomfort

Normal

Inspection

Chess wall intact, no tenderness

Elevated chest wall

Due to abnormalities in lungs

Auscultation

Chest symmetric

Chest symmetric

Normal

Inspection

Symmetrical bilaterally midline and inverted, no sign of discoloration, inflammation

Symmetrical bilaterally midline, with discoloration and inflammation

Normal

Palpation

No tenderness

Rigid and tender

Associated with gastroinstestinal abnormalities

Inspection and palpation

No edema No lesions

No edema No lesions

Normal

Inspection and palpation

No edema No lesions

No edema on her feet and legs nor lesions on legs

Normal

LABORATORY ANALYSIS HEMATOLOGY RESULT -

129 0.37 3.82 175 98.2 37. 7 343 15.2

(120 – 160 g/L) (0.38 – 0.47) (4.5 to 6.0 x 109 /L) (150 – 400 x 109 /L) (80 – 100 fL) (26 – 32 pg) (320 – 360 g/L) (4.5 – 11 x 109 /L)

-

96.9 2.6 0.5

(35 – 65) (20 – 40) (2 – 8)

Physical Test: Color Transparency pH Specific Gravity

-

amber turbid 5.0 1.030

Chemical Test Albumin Sugar Ketone Blood Bilirubin Nitrite Leukocytes

-

Trace Negative Positive Positive Negative Negative Negative

Hemoglobin in mass concentration Erythrocyte Volume Fraction Erythrocyte Number Concentration Thrombocyte Number Concentration Mean Corpuscular Volume (MCV) Mean Corpuscular Hemoglobin (MCH) Mean Corpuscular Hemoglobin Content Leukocyte Number Concentration WBC Differential Count: Neutrophils Lymphocytes Monocytes URINALYSIS RESULT

DRUG STUDY D5LRS + BIOMIX CELEMIN ½ x 12⁰ OD KETOROLAC 30 mg IV q 8⁰ GENERIC NAME: Ketorolac BRAND NAME: Toradol CLASSIFICATION: Nonsteroidal anti-inflammatory agents, nonopioid analagesics DOSAGE: 30mg/amp1 amp IM MECHANISM OF ACTION: - Inhibits prostaglandin synthesis, producing peripherally mediated analgesia - Also has antipyretic and anti-inflammatory properties. - Therapeutic effect:Decreased pain INDICATION: Short term management of pain (not to exceed 5 days total for all routes combined)

CONTRAINDICATIONS: - Hypersensitivity - Cross-sensitivity with other NSAIDs may exist¨Pre- or perioperative use - Known alcohol intoleranceUse cautiously in: 1) History of GI bleeding 2) Renal impair-ment (dosage reduction may be required) 3) Cardiovascular disease SIDE EFFECTS/ ADVERSE EFFECTS: - CNS: 1) drowsiness 2) abnormal thinking 3) dizziness 4) euphoria 5) headache- RESP: 1) asthma 2) dyspnea - CV: 1) edema 2) pallor 3) vasodilation - GI: 1) GI Bleeding 2) abnormal taste 3) diarrhea 4) dry mouth 5) dyspepsia 6) GI pain 7) nausea - GU: 1) oliguria 2) renal toxicity 3) urinary frequency - DERM: 1) pruritis 2) purpura 3) sweating 4) urticaria - HEMAT: 1) prolonged bleeding time - LOCAL: 1) injection site pain - NEURO: 1) paresthesia - MISC: 1) allergic reaction, anaphylaxis NURSING IMPLICATIONS/RESPONSIBILITIES: - Patients who have asthma, aspirin-induced allergy, and nasal polyps are at increased risk for developing hypersensitivity reactions. Assess for rhinitis, asthma, and urticaria. - Assess pain (note type, location, and intensity) prior to and 1-2 hr following administration. - Ketorolac therapy should always be given initially by the IM or IV route. Oral therapy should be used only as a continuation of parenteral therapy.

- Caution patient to avoid concurrent use of alcohol, aspirin, NSAIDs, acetaminophen, or other OTC medications without consulting health care professional. - Advise patient to consult if rash, itching, visual disturbances, tinnitus, weight gain, edema, black stools, persistent headche, or influenza-like syndromes (chills,fever,muscles aches, pain) occur. - Effectiveness of therapy can be demonstrated by decrease in severity of pain. Patients who do not respond to one NSAIDs may respond to another. HYDROCORTISONE 100 g IV q 8⁰ x 1 dose more HYDROCORTISONE ACETATE Anusol HC, CaldeCort, Carmol HC, Colifoam, Cortaid, Cortamed, Cort-Dome, Cortef Acetate, Corticaine, Cortifoam, Cortiment , Epifoam, Hydrocortone Acetate HYDROCORTISONE CYPIONATE Cortef Fluid HYDROCORTISONE SODIUM PHOSPHATE Hydrocortone Phosphate HYDROCORTISONE SODIUM SUCCINATE A-Hydrocort, Solu-Cortef HYDROCORTISONE VALERATE Westcort Classifications: skin and mucous membrane agent; antiinflammatory; synthetic hormone;adrenal corticosteroids; glucocorticoid; mineralocorticoid Pregnancy Category: C NURSING IMPLICATIONS Assessment & Drug Effects  Establish baseline and continuing data on BP, weight, fluid and electrolyte balance, and blood glucose.  Lab tests: Periodic serum electrolytes blood glucose, Hct and Hgb, platelet count, and WBC with differential.  Monitor for adverse effects. Older adults and patients with low serum albumin are especially susceptible to adverse effects.  Be alert to signs of hypocalcemia (see Appendix F).  Ophthalmoscopic examinations are recommended every 2–3 mo, especially if patient is receiving ophthalmic steroid therapy.  Monitor for persistent backache or chest pain; compression and spontaneous fractures of long bones and vertebrae present hazards.  Monitor for and report changes in mood and behavior, emotional instability, or psychomotor activity, especially with long-term therapy.  Be alert to possibility of masked infection and delayed healing (antiinflammatory and immunosuppressive actions).  Note: Dose adjustment may be required if patient is subjected to severe stress (serious infection, surgery, or injury).  Note: Single doses of corticosteroids or use for a short period (