Case presentation of basal cell carcinoma of face no 4
Submitted toMr.P.YonatansirAssociate professerJgcollege of nursingAhmedabad Submitted by MrsHeena Mehta S.Y.M.Sc Nursing
Jg college of nursing AhmedabadSub-Medical Surgical NursingTopic- Basal cell carcinoma of faceSubmitted to-Mr.P.YonatansirSubmitted by-MrsHeena MehtaSr no content Page no1 Identification data2 History3 Physical examination4 Investigation5 Disease condition6 Definition7 Pathophysiology8 Management9 Nursing diagnosis10 Health teaching11 Bibliography
IDENTIFICATION DATAPATIENT’S NAME: JivatibenBhojabhaiGajjarIndoor.no: F 56854AGE:64 yearsSEX:FemaleDATE OF ADMISSION`:12-1-2012DR’S UNIT: Unit-2 Dr.prakashpatelWARD: cancer female medical wardMARRITAL STATUS: marriedRELIGION: HinduEDUCATION: Illiterate .OCCUPATION: House wifeADDRESS:Jetpur,RajkotDIAGNOSIS:Basal cell carcinoma of the faceHEIGHT: 146CmWEIGHT: 5 Kg
PRESENTING COMPLAINS:Patient having complained of following:-Fever-Itching on face-Black ulcer on the face-Dryness of face skin-Indigesion-WeaknessPRESENT HISTORY:Jivatiben has complain of the dryness of the face skin, itching of the face , black ulcer on theface, loss of apitite and weakness since last 8 month so she has to gone for treatment atprivate hospital in Jetpur (Rajkot) but symptoms not relieve itching constant occure than sherefer to the civil hospital for medication.PAST HISTORY:PAST MEDICAL HISTORY:Upto 64 year she has lot off time taken medication for minor disease but not need anyhospitalization ,symptomatic medication taken for three to five day and symptoms relievebut last 8 month she was suffering from the skin disease and symptoms not relieve thus refer
civil hospital and finally after total investigation she diagnose BASAL CELL CARCINOMAOF THE FACE and admit in the civil hospital for treatment.PAST SURGICAL HISTORY:No any surgical treatment needed Jivatiben, No any surgery done to the Jivatiben.DIET HISTORY:Jivatiben taken normal diet in her life. She has a farm so her husband grownormaly all types of vegetables in his farm .PERSONAL HISTORY: Diet : vegetarian & taking all type of small amount diet Appetite : Decreased Sleep :disturb Micturation : No burning micturation Bowel habit: Abnormal habits Smoking : No Alcohol : No Drugs : No Tobacco : No No any other habitsFAMILY HISTORY:In her family no any family members have history of any Hypertension, Diabetes mellitus,Ischemic heart disease, Epilepsy, Asthma, Storks, Arthritis, Cancer or any other disease. Herfather suffering from the tuberculosis and expired with this disease.Sr. Name of Family Age in Relationship Education OccupationNo. Members Year With patient 1 BhojabhaiBudhabh 7oYrs. Husband Illiterated Farmer
aiGajjar 2 JivatibenGajjar 64Yrs Patient Illiterated Housewife 3 JentibhaiGajjar 46Yrs Son 8th pass Farmer 4 NandubenGajjar 40Yrs Son’s wife 7th pass Housewife 5 Ramesh Gajjar 20Yrs Grand son 12th pass Farmer 6 Neeta Gajjar Yrs Grand 10th - daughter 7 RasikGajjar 25 son B.Com - 8 NanjiGajjar 20 son B.Com -SOCIOECONOMIC HISTORY:In Jivatiben’s house , her husband and elderson as a farmer so they work in farm and growseasional vegetables and cereals for family and for sale so her income is not fix sometime herfamily earn more money and some times her family earn less money.PHYSICAL EXAMINATION:VITAL SIGNDate Temp ( Pulse Respiration(/min) BP (mm of F) (/min) Hg)16-07- 100 F 100/min 20/min 118/74201217-07- 99 F 126/min 24 min 122/64201218-07- 99 F 120/min 26 min 114/78201219-07- 98.6F 116/min 20 min 120/742012GENERAL OBSERVATION: Sensorium: She is conscious and well oriented Foul body odour: no any bad odour from her body Foul breath : no Posture : normal Hair: Brown hair, clean no any dandruff.
GENERAL APPERANCE: Body image: normal Health: Unhealthy Activity: less activeMENTAL STATUS:Consciousness: conscious Look: weakness, fatigue due to her disease.Posture Body curves: normal Movement: Full movement(if given deep pain than small reflection was done by patient)Height: 146cm Weight: 67kgSKIN CONDITION: Color: pallor Texture: Rough skin Temperature: warm Lesions: no lesions presentHEAD & FACE: Scalp: clean Face: pale, fatigue, fear, anxietyEYES: Eyebrow: normal Eye lashes: no infection, not open by patient Eyelids: no any injury or oedema is present Eye balls: not sunken Conjunctiva: pale Sclera: no jaundiced Pupils: constricted Vision: react to lightEAR: External ear: no discharge present
Hearing: normalNOSE: External nares: Redness present Nostrils: normal. keeping face mask for proper oxygenationMOUTH & PHARYNX: Lips: dry odour of the mouth: not present Teeth: normal Mucus membrane: dry Tongue: pale and moistNECK: Lymph node: Not palpable Thyroid gland: normal Range of motion: flexion, extension and rotation when done by someone, patient able to done by own self.CHEST: Thorax: expansion Breath sound: No any sound heard Heart: normalABDOMEN: Observation: no skin rashes and scar Auscultation: reduced bowel sound Palpation: no tenderness presentPercussion: not presence of gas, fluid or massesEXTREMITIES: Lower extremities: fully movements of lower extremities. mildoedema present Upper extremities: can move both hands but mild oedema is presentGenital and rectum: No enlarged inguinal lymph nodes, No hemorrhoids, no enlargement of prostate glands. Bladder & Bowel Pattern: Abnormal.
INVESTIGATION:Serum Biochemistry test: Investigation In patient Normal valueHemoglobin 12 % gm% 14 – 17 gm %.RBC 100 mg/dl 153mg/mlUREA 24mg/dl 15-45mg/dlWBC 9,200/cumm 4000-11000/cummS.creat. 0.59mg/dl 0.7-1.5mg/dlSGPT 36U/L 0-55U/LS. phosphate 108 U/L <50-150U/LS.Billirubin 0.7mg/dl 0.2-1.2mg/dlBLOOD CHEMISTERYFASTING 90.0mg/ dl 70-110mg/dlCHOLESTROL 174 mg/dl >240.0mg/dlSerum Electrolytes: Investigation In patient Normal valueS. Na+ 144.3 meq/L 135-145meq/LS.K+ 4.62 meq/L 3.5-5.5 meq/LChloride 105 97-108X-RAY CHEST: Olcg in bothlungsECG:wnlMEDICATIONCHEMOTHERAPY GIVEN AFTER SURGERY-Injection 5FU and cyclophosphamide regimen every 3week for three cycle.-Injection amikasine 500gm i/v 12hourly.-Injection voveran 1 ampoule i/v 12hourly.- Injection Ondensten 1 ampoule i/v sos- Tablet-Rantac 150 mg 1 bd.-Tablet- MV/BC 1 bd
Maintain intake and output chart daily Contineus observation of the patient on monitor for any abnormal symptoms. TPR chart 1 hourly Monitoring continuously for blood pressure, respiration rate, pulse, and for oxygen saturation. Care taken of catheter daily Care taken of all tubes which are inserted Watched for respiratory failure . Changed the dressing and adhesive tap at the site of intracath. DISEASE CONDITIONANATOMY AND PHYSIOLOGY OF SKIN-The skinis the largest organ in the body, comprising about 15% of the body weight. Thetotal skin surface of an adult ranges from 12 to 20 square feet. In terms of chemicalcomposition, the skin is about 70% water, 25% protein and 2% lipids. The remainderincludes trace minerals, nucleic acids, glycosoaminoglycans, proteoglycans and numerousother chemicals.
The skin consists of three main layers: epidermis, dermis and subcaneous tissue.The EpidermisThe epidermis is the topmost layer of the skin. It is the first barrier between you and theoutside world. The epidermis consists of three types of cells keratinocytes, melanocytes andLangerhans cells. Keratinocytes, the cells that make the protien keratin, are the predominanttype of cells in the epidermis. The total thinkness of the epidermis is usually about 0.5 - 1mm. At the lowermost portion of the epidermis are immature, rapidly dividingkeratinocytes. As they mature, keratinocytes lose water, flatten out and move upward.Eventually, at the end of their life cylce, they reach the uppermost layer of the epidermiscalled stratum corneum. Stratum corneum consists mainly of dead keratinocytes, hardenedproteins (keratins) and lipids, forming a protective crust. Dead cells from stratum corneumcontinuously slough off and are replaced by new ones coming from below. The skincompletely renews itself every 3 - 5 weeks. Most mild peels work by partly removing thestratum corneum and thus speeding up skin renewal.Another significant group of cell in the epidermis are melanocytes, the cells producingmelanin, the pigment responsible for skin tone and color. Finally, Langerhans cells areessentially a forepost of the immune system in the epidermis. They prevent unwantedforeingn substances from penetrating the skin.The condition of epdermis determines how "fresh" your skin looks and also how well yourskin absorbs and holds moisture. Wrinkles, however, are formed in lower layers.The DermisThe dermis is the middle layer of the skin located between the epidermis and subcutaneoustissue. It is the thickest of the skin layers and comprises a tight, sturdy mesh of collagen andelastrin fibers. Both collagen and elastin are critically important skin proteins: collagen isresponsible for the structural support and elastin for the resilience of the skin. The key typeof cells in the dermis is fibroblasts, which synthesize collagen, elastin and other structuralmolecules. The proper function of fibroblasts is highly important for overall skin health.The dermis also contains capillaries (tiny blood vessels) and lymph nodes (depots ofimmune cells). The former are important for oxygenating and nourishing the skin, and thelatter -- for protecting it from invading microorganisms.Finally, the dermis contains sebacious glands, sweat glands, hair follicles as well as arelatively small number of nerve and muscle sells. Sebacious glands, located around hairfollicles, are of particular importance for skin health as they produce sebum, an oilyprotective substance that lubricates and waterproofs the skin and hair. When sebaciousgland produce too little sebum, as is common in older people, the skin becomes excessivelydry and more prone to wrinkling. Conversely, overproduction or improper composition ofsebum, as is common in adolescents, often leads to acne.The dermis is the layer responsible for the skins structural integrity, elasticity andresilience. Wrinkles arise and develop in the dermis. Therefore, an anti-wrinkle treatementhas a chance to succeed only if it can reach as deep as the dermis. Typical collagen andelastin creams, for example, never reach the dermis because collagen and elastin moleculesare too large to penetrate the epidermis. Hence, contrary to what some manufacturers ofsuch creams might imply, these creams have little effect on skin wrinkles.
Subcutaneous tissueSubcutanous (hypodermis) tissue is the innermost layer of the skin located under the dermisand consisting mainly of fat. The predominant type of cells in the subcutaneous tissue isadipocytes or fat cells. Subcutaneous fat acts as a shock absorber and heat insulator,protecting underlying tissues from cold and mechanical trauma. Interestingly, mostmammals lack subcutaneous tissue because their fur serves as a shock absorber and heatinsulator. Sweat glands and minute muscles attached to hair follicles originate insubcutaneous tissue.The loss of subcutaneous tissue, often occurring with age, leads to facial sag andaccentuates wrinkles. A common procedure performed by dermatologists to counteract thisprocess is to inject fat (collected elsewhere in the body) under the wrinkles on the face .DEFINITION:Basal cell carcinoma is the most common form of cancer worldwide andaccounts for about 80% of all cases of skin cancer.CAUSES:In Book In PatientRadiation expose, UV Rays noGene Maturations May beArsenic exposure through ingestion noImmunosuppression May beXerodermapigmentosum May beEpidermodysplasticverruciformis noNevoid basal cell carcinoma syndrome NoBazex syndrome NoPrevious nonmelanoma skin cancer noRombo syndrome NoAlcohol consumption no
Types of basal cell carcinoma of the skinIn Book In My PatientNodular: About 60% of BCCs are nodular. There is small nodes seen over the face.They start out as flat, well-defined lesions,then often become small bumps, whicheventually collapse in the middle, leaving araised ring on the border. Most nodularBCCs are on the face and so can bedisfiguring if not treated promptly.Pigmented: Pigmented BCCs are similar to There is Black pigmentation seen over nodesthe nodular type, but they can have brown orblack spots in them. They can be confusedwith some types of melanoma.Fibrosing or Sclerotic: These BCCs areusually found on the face and look similar toscars. They are usually firm, ill-defined at theborder, flat or slightly depressed, yellowishin color, and the surface tends to be smoothand shiny.Superficial: This type comprises about 15%of BCCs. They spread outward from a red,well-defined, scaly patch, most commonlyfound on the trunk and limbs. They are easilyconfused with psoriasis or eczema.Fibroepithelioma of Pinkus: This is a raretype of BCC. It tends to be a smooth,elevated, small nodule found on the back,extremities, groin, or sole of the foot. Asthose are not sun-exposed areas, this diseaseis probably not sun-related.PATHOPHYSIOLOGY:Over exposure to sun leads to the formation of thymine dimers, a form of DNA damage.
cumulative DNA damage leading to mutations.Apart from the mutagenesis, over exposure to sunlight depresses the local immune system,Basal-cell carcinoma also develops as a result of Basal-Cell Nevus Syndrome,Developed tumors of the jaw, palmar or plantar (sole of the foot) pits, calcification ofthe falxcerebri (in the center line of the brain) and rib abnormalities.which inhibits the hedgehog signaling pathway.A mutation in the SMO gene, which is also on the hedgehog pathway, also causes basal-cellcarcinomaCLINICAL MENIFESTATION:In Book In Patient Presentskin bump or growth that is: Pearly or waxy White or light pink Flesh-colored or brownA skin sore that bleeds easily PresentA sore that does not heal PresentOozing or crusting spots in a sore Not PresentAppearance of a scar-like sore without Presenthaving injured the areaIrregular blood vessels in or around the Not PresentspotA sore with a depressed (sunken) area in Not Presentthe middleASSESSMENT & DIAGNOSTIC FINDINGS:
IN BOOK IN PATIENT - Taking a thorough history - Done including family history - Physical examination (note BP - Done & weight) - Laboratory work (cholesterol - Done levels, glucose ) skin biopsy - Done Shave biopsy uses a thin surgical blade to shave off the top layers of skin. This is the most common method for diagnosing BCC. Punch biopsy uses a round, cookie cutter-like tool. It is used to take a deeper skin sample.MANAGEMENT: Curettage and electrodessication Surgical excision (removal) Mohs surgery (also known as "micrographic surgery"), especially if the lesion is on the face, is recurrent, has a diameter of greater than 2 cm, or is the sclerotic type Topical creams such as imiquimod is FDA-approved for the treatment of superficial BCCs not on the face, although studies have shown it can be effective against nodular BCC as well Excision Simple surgical excision (removal) is used to treat both primary and recurrent tumors. The procedure involves surgically removing the tumor and a certain amount of normal-appearing skin surrounding it (the "margin"): For basal cell and squamous cell carcinomas, margins are often 2 to 4 mm. The cure rates following excision are 95% and 92% for primary BCC and SCC, respectively, and are dependent on the site, size, and pattern of the tumor. Excision may be performed in the outpatient or inpatient setting depending on the extent of the cancer. Topical Creams Since its approval in 2004, the immune systemactivator imiquimod (also known by the brand nameAldara) has been a commonly prescribed topical (skin only) cream for small superficial and nodular basal cell carcinomas, as well as a pre-cancerous condition called actinic keratosis. It is spread on the lesion five times per week, usually for six weeks, and completely clears the skin in about 88% of patients or more, depending on the exact type of cancer. Another cream for superficial BCC is 5- flourouracil (Carac or Efudex), a chemotherapy drug that is also used intravenously. These treatments usually dont leave any scars, but they can cause considerable pain and swelling as they work. Several other creams are being tested now,
including ingenolmebutate(PEP005), which is derived from a plant called the "petty spurge." Curettage and Electrodesiccation Curettage and electrodesiccationis a simple, quick and effective method for destroying small basal cell and squamous cell carcinomas. After scraping away the growth with a long spoon-like instrument called a curette, the physician uses a mild electric current to destroy any remaining abnormal cells. This scraping and cauterizing process is typically repeated three times, and the wound tends to heal without stitches. It is best for primary, not recurrent, lesions. The cure rates depend on the site: high-risk locations (nose, ear, chin, mouth) have a recurrence rate of 4% to 18%, depending on the tumor size. Recurrence rates decrease to 3% for tumors at low-risk sites of the trunk and extremities. Overall, the 5-year cure rates for primary BCC and SCC treated with C and E are 92% and 96%, respectively. Mohs Surgery TheMohs procedure (also known as Mohs micrographic surgery or margin controlled excision) is an advanced technique developed in the 1940s by Dr. Frederic E. Mohsfor removing lesions due to basal or squamous cell carcinoma. It involves removing thin sections of the skin growth, layer by layer. Each layer is then examined under the microscope, and removal of layers continues until no cancerous cells remain. It has the highest cure rate of any skin cancer treatment and doesnt cause as much scarring as other methods. It is especially useful for treating recurring skin cancer, larger tumors, tumors on the ear, eyelid, nose, lip, or hand, tumors in sites prone to recurrence, and the sclerotic subtype of basal cell carcinoma. It is the "gold standard" treatment: The 5-year recurrence rate is 1% for BCC and 3% for SCC. However, it is more costly, time-consuming, and labor-intensive than other methods.MEDICAL MANAGEMENT: - Chemotherapy in four cycle with Adreamycine andcyclophosphemide. - Analgesics - AntibioticsNURSING MANAGEMENT: - Identify at risk patients, & teach lifestyle modifications to prevent development any complication. - Teach patient to control cholesterol levels through dietary reduction of cholesterol intake, exercise, smoking cessation. - Note & report findings from history, physical examination, & laboratory results that indicate hypertension or diabetes, &teach to control blood pressure by taking treatment in the nearest hospital.NURSING DIAGNOSIS:
1. Risk for infection related to decrease immune system. 2. Altered body temperature due to presence of infection. 3. Imbalance nutritional level less than body requirement related to loss of appetite. 4. Activity intolerance related to disease. 5 Impaired body image due disease. 6 Altered self image and confidence due to fegure. HEALTH TEACHING: Explain patient’s relatives about discharge planning. Give advice about regular medication as per timing. Advice given about good nutritive diet. Advice given for prevention of infection management.PreventionThe best way to prevent skin cancer is to reduce your exposure to sunlight. Ultraviolet lightis most intense at midday, so try to avoid sun exposure during these hours. Protect the skinby wearing hats, long-sleeved shirts, long skirts, or pants.Always use sunscreen: Apply high-quality sunscreens with SPF (sun protection factor) ratings of at least 15. Look for sunscreens that block both UVA and UVB light. Apply sunscreen at least 30 minutes before going outside, and reapply it frequently. Use sunscreen in winter, too.Possible ComplicationsUntreated, basal cell cancer can spread to nearby tissues or structures, causing damage.This is most worrisome around the nose, eyes, and ears.Explain about follow up care.
BIBLIOGRAPHY: 1. Bennette and Plum; “TEXTBOOK OF MEDITION ; 10thedition, 1996; W.B. Saunders Company, New York : 1996. PP : 2. Black J.M; “MEDICAL SURGICAL NURSING; 5th edition, 1999 ; W.B. Saunders Company, Philadelphia. PP: 3. Brunners&Suddarth’s; “TEXT BOOK OF MEDICAL SURGICAL NURSING VOL-_1”;10th edition, 2004; Elsevier Publishers, New Delhi, India. PP: 4. B T Basavanthappa;”TEXT BOOK OF NURSING THEORIES”,Jaypee brothers Medical Publishers ,New Delhi.PP: 40- WEBSITES: - http://www.wikipedia.com. - http://www.patho.skindisease.org/.com.in - http://www.google.com. - http://www.medicine.com.