Case Study

July 14, 2017 | Author: Sarah Gatuz | Category: Esophageal Cancer, Pain Management, Esophagus, Pain, Gastroesophageal Reflux Disease
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ARELLANO UNIVERSITY College of Nursing Legarda, Manila S.Y. 2012

Submitted to:

Submitted by: Sarah Joy A. Gatus III-1 CMO#30 group 3



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.

II. Nursing History a) Past health history - The most recent hospitalization of Mrs. N.S was last 2009 due to difficulty of breathing associated with other manifestations of hypersensitivity, such as eczema and hat fever and was later diagnosed with Asthma. After 2 weeks, she was sent home without any medications. - In 2007 she also diagnosed with PTB or Pulmonary tuberculosis due to chronic coughing. She was taken combinations of antibiotics like Rifampicin, Isoniazid, pyrazinamide and ethambutol at home and was said to be effective. - In 2005 she also diagnosed with Hypertension due elevated blood pressure above the normal range expected. After 1 week, she was sent home with diuretic medications and was said to be effective. b) History of present illness Two days prior to admission the patient started to complaint of difficulty in swallowing associated with vomiting, weight loss, and loss of appetite. No consultation done persistence of condition. c) Family health history - The family has history of Cancer, Hypertension and Diabetic Mellitus.

III. Theoretical frame work Virginia Henderson (1955, 1966, 1969, 1978) Theory: Definition of nursing Henderson’s Definition of Nursing was formulated a definition of the unique function of nursing. This definition was a major stepping stone in the emergence of nursing as a discipline separate from medicine. Her definitions are various assumptions about the individual: a.) the needs to maintain physiologic and emotional balance, b.) requires assistance to achieved health and independence or a peaceful death, and c.) needs the necessary strength, will, or knowledge to achieve or maintain health. Patient N.S. has a esophageal cancer, that’s why we cannot blame her of her thoughts about death. She needs or she requires assistance to achieved good health so that she will be encouraged to live and fight the illness she felt. Some of the Fundamentals of needs that the Patient requires or need to achieve: - Eating and Drinking adequately - Eliminating Body wastes - Sleeping and resting

IV. Gordon’s functional Pattern


Health Perception


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”.

- She wants to take away the IUD, she verbalized, “may sumasakit na sa puwera ko, gusto ku na ipatanggal ung IUD”.

 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 .”

 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

Interpretation and Analysis

Self-concept is one’s mental image of oneself. A positive self-concept is essential to a person’s 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 one’s interaction with others.  The patient don’t likes to eat the food rationed by the hospital, the patient verbalized “ wala namang lasa mga pagkain dito sa ospital kaya nagpapabili ako sa

an alternative, they labas. Lalo ako are fond of eating manghihina sa mga canned goods pagkain dito.” specially sardines if  She always asks they don’t 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 doctor’s order.




 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  Can’t perform  considered washing ROM exercises clothes as her only because she exercise experiences pain  doesn’t 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.


   

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

 does not smoke cigarettes  does not drink alcoholic beverages  does not use any forms of recreational drugs

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.

 does not smoke cigarettes  does not drink alcoholic beverages  does not use any forms of recreational drugs


5. Substance Use

Sleep and Rest

 usually sleeps at  the patient can’t 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

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

Cognitive Patterns

describes sleep as deep  Does not nap during the afternoons or any time of the day besides night time.

after waking up  Sleeps lightly and is easily awaken by disturbances in the environment

on less.

The patient graduated in 4th year high school. Because of financial problem she’s not be able to continue her studies. When I asked her cognitive skills, she doesn’t 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.

There were no changes in the cognitive perception of the client.


This is a normal sleep pattern in the hospital ward.

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.

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.”

 inactive sex life

Sexual Activity

There were no changes to role and relationship of the patient as verbalized by the son

 inactive sex life

Normal The effectiveness if family communication determines the family’s 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 person’s expression of sexuality. This should

be taken into account when it involves a person’s 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.”

Coping/Stress Tolerance

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

Occupational Health and Safety)  She does always go to the church every Friday and Sunday with some of her daughter.

Values and belief Pattern

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

General Appearance



Actual Findings

Interpretation and Analysis


Erect posture, coordinated, smooth and steady gait

Poor gait

Deviation from normal, the patient has a poor gait due to joint pain

Varies from light to deep brown; from ruddy pink to light pink; from yellow overtones to olive.

Light brown and even with freckles


Sunken eye balls


Dry and pale

malnutrition ,irregular bowel movements

1. Posture / Gait

2. Skin Color

3. Eyeseyeballs



Color white

4. Mouth- lips inspection

light Reddish and pinkish or light brown

5. Personal Hygiene / Grooming

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.


Speech should be clear, well paced and coherent. Language should seem appropriate for educational level.

She doesn’t speaks clearly but able to express her thought.

Normal for her age

6. Verbal Behavior


Facial expression and body movement should be appropriate with the mood and the answers to the questions

Her facial expression is appropriate to the situation.

1. Temperature

36.5 – 37.5 °C



2. Pulse Rate

60 – 100 bpm



3. Respiratory Rate

12 – 20 cpm

22 cpm


4. Blood Pressure

90-120 (Systolic)

140 / 80 mm Hg


7. NonVerbal Behavior



60-90 (Diastolic) 5. Weight


Body Parts


Actual Findings

Interpretation and Analysis

Scalp >> Color, appearance

>> Areas of


>> 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



area of tenderness

*Hair >> Color

>> Black

>> no tenderness

>> white and gray hair >>Evenness of growth over the scalp

>>Evenly distribution of hair

>>Thickness or thinness

>>Thick hair (Barbara Kozier, et al.,

>>Thin hair

>>Silky, resilient hair

>> Silky, resilient hair

>>Texture and oiliness

Normal for her age

>>Hair is not Deviation from evenly distributed normal due to aging

Normal due to aging


>>Presence of infections or infestations

>>No infection or infestation

>>No infection or infestation

>>Convex curvature; angle of nail plate about 160 degrees

>>round nails, about 160 degree nail base


*Nails >>Curvature and angle of the fingernail plate




and toenail texture

>>Smooth texture

>>thick, hard and smooth nails

>>Fingernail and toenail bed color

>>Highly vascular and pink in lightskinned clients; dark-skinned clients may have brown or black pigmentation in longitudinal streaks

>> pale nail bed

Deviation from normal due to poor peripheral circulation

Normal >>Tissues surrounding the nails

>>Intact; no hangnails >>Intact epidermis

Normal >>Blanch test

>>Nail beds >>Prompt return of return to pink pink or usual color after 3 seconds. (generally less than four seconds)

*Skull and Face >>Skull: size, shape, and symmetry

>>Rounded (normocephalic and symmetrical, with frontal, parietal, and occipital prominences); smooth skull contour

>>Skull: nodules or masses and

>>Rounded shape, symmetrical


Normal >>Absence of

depressions >>Smooth uniform consistency; absence of nodules or masses

nodules or masses

>>Facial features >>Symmetric or slightly asymmetric facial features; palpebral fissures equal in size; symmetric nasolabial folds

>> asymmetrical facial features

Normal >> head in central position


>>Eyes: edema and hollowness >>Deviation: periorbital edema; sunken eyes >>Symmetry of facial movements (facial nerve)

Deviation from normal due to aging

>>Symmetric facial movements

>>Eyes are hollow, no edema

>> Asymmetrical facial movements

Deviation from normal due to arthritis

*Eye structures and visual acuity >>Eyebrows

>>Hair evenly distributed; skin intact >>Eyebrows symmetrically aligned; equal movement

>>Eyelashes >>Equally distributed; curled slightly outward

>>Evenly distributed, symmetrical movement and alignment


>>Distributed evenly; shot lashes, curled outward




>> 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

>>Bulbar conjunctiva

>>Palpebral conjunctiva

>>Lacrimal gland

>>Lacrimal sac and nasolacrimal duct

>> Bilateral blinking, involuntary, at approximately 15 blinks/min >>Transparent; capillaries sometimes evident >>Shiny, smooth, and pink or red

>>Symmetrically closed, no discharge and discoloration


>> both eyes blink at the same time Normal

>> Transparent

>> Pale conjunctiva

>>No edema or tenderness over lacrimal gland

>>No edema or tearing


Deviation from normal due to poor lack of sleep


>> No edema or tenderness Normal

>> No edema



shiny, and smooth; details of the iris are visible >> Iris are visible, transparent shiny

>>Pupil: color, shape, symmetry of size, direct and consensual reaction to light and accommodation

>>Extraocular Muscles (Oculomotor, Abducens, Trochlear Nerves)

>>Visual acuity >>>Near vision

>>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


>> 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

>>Eyes are coordinated, move in unison, with parallel alignment >>>Able to read newsprint >> unable to read newsprint

*Mouth and Oropharynx

>>Uniform pink color (darker, e.g.

>>Symmetrical, dry, no swelling


>>Lips: symmetry of contour, color, and texture

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)

>>Teeth and gums

>> 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)

Deviation from normal due to aging

Normal >> pink color on tongue borders >>No lesions >> Raised Papillae

>>Surface of the tongue

>>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

>>Tongue movement (hypoglossal nerve)

>>Moves freely; no tenderness

Normal >> Smooth tongue base

>>Smooth tongue base with prominent base >>Base of the tongue, floor of the mouth, and frenulum

*Musculoskeletal system >>Muscles for size

>>Muscles for fasciculation or tremors



>>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

>>Equal on both sides of the body

>>not equal on both sides

Deviation due to aging

>>No fasciculation or tremors

>> without tremors


Deviation due to

aging >>Normally firm >> not firm

>>Muscle tonicity

>>Equal strength on each body side >>Muscle strength

>> equal in strength, both arms are slightly weak

Deviation from normal due to body weakness and due to aging

normal >>No deformities

>>Skeleton for normal structure and deformities


>> no deformities >>No tenderness or swelling >> no tenderness and swelling


VI. Laboratory and Diagnostic Examinations Results (Latest) Laboratory Results Hemoglobin Hematocrit MCV MCH

108.0 0.34 83 normal 26


4.12 32 13.1


WBC Neutrophils Basophils Monocytes Eosinophils Platelet count MPV

6.42 72.7 0.2 5.9 0.6 425 8.6



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

VII. Drug study

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. That’s 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

X. Nursing care plan Assessment


Subjective: The patient verbalized, “nahihirapan ako lumunok kapag kumakain ako”.

Impaired Swallowing esophageal cancer 70% blockage of esophagus by mass, describing patient difficulty swallowing, strict NPO

Objective: - Dysphagia -Weight: 95



Short term goal:

~Put up sign NPO Patient and advise staff of NPO status

The Client will maintain strict NPO while in the hospital for the next 48 hours or until reassessed.

Client will remain free from aspiration, clear lungs, and temperature within normal range for hospital stay.

~Be alert to signs and symptoms of aspiration

~Maintain Adequate nutrition through feeding tube, the client is NPO and needs' to get the proper nutrition



~To insure that patient does not aspirate


~To prevent aspiration because it is very serious and can cause death... ~for His body to function correctly

~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

While the client remained NPO in the hospital, the client did not suffer from aspiration.






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”

Constipation related to change in usual foods and eating patterns.

short term goal:

~Determine fluid intake.

~to note deficits.

The Client will Establish and regain normal pattern of bowel functioning for 8 hours or until reassessed

~Instruct and encourage in balances fiber and bulk in diet.

~to improve consistency of stool and facilitate passage through colon.

Objective: -Anorexia -Atypical presentations in older adults.

~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.

~to stimulate contractions of the intestines.

~Administer stool softeners, mild stimulants, or bulk-forming agents as ordered by the Doctor.

~to facilitate to turn to usual pattern of elimination.

~Provide sitz bath after stools.

~for soothing effect to rectal area.

Evaluation MET After 8 hours of Nursing Intervention the patient can establish and regain normal pattern of bowel functioning.

XI. Discharge planning a. Medications Tell the patient to take her medication in time, as ordered by the physician to avoid pain and further complications. Explain also to the client the importance of the drug, her compliance and the continuation of the drug to be used. The following are the drugs the patient needs to take with its dose and frequency:  Paracetamol + tramadol (Dolcet) 325 mg per tablet for pain when necessary. b. Exercise  Walking exercise.  Deep breathing exercise. c. Treatment  Nutritional Therapy- According to the National Cancer Institute, about one-third of all cancer deaths are related to malnutrition. For cancer patients, optimal nutrition is important. Cancer can deplete your body's nutrients and cause weight loss. Cancer and cancer treatment can also have a negative effect on your appetite, and your body's ability to digest foods. These factors may leave you in a vulnerable condition - high nutrient need, and low nutrient intake.  Pain Management Most patients with advanced cancer experience pain during the course of their disease. Cancer pain may be acute or chronic. Acute pain generally results from tissue damage and is of limited duration. Once the cause of pain has been identified, it can be successfully managed. Chronic pain, on the other hand, is persistent -- usually greater than three months in duration. Because the cause of chronic pain often cannot be altered, your nervous system will adapt, which may cause depression, anxiety and/or insomnia. 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

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 dietThere 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.

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