Submitted toMr.P.Yonatan sirAssociate professerJgcollege of nursingAhmedabad Submitted MrsHeena Mehta S.Y.M.sc nursing Jg nursing college
AhmedabadSub-Medical surgical nursingTopic- Cancer esophagusSubmitted to-Mr. P. YonatansirSubmitted by-MrsHeena MehtaSr no Content Page no1 identification2 history3 Physical examination4 investigation5 Disease condition6 defination7 pathophysiology8 management9 Nursing diagnosis10 Health teaching11 Bibliography
IDENTIFICATION DATAPATIENT’S NAME: ChetangiriDevgiriGoswamiIndoor . NO: F 59456AGE:40 yearsSEX:MaleDATE OF ADMISSION`: 18-07-2012DR’S UNIT: Unit-3 Dr.DevenpatelWARD: cancer male preoperative ward no-3MARRITAL STATUS: marriedRELIGIO: HinduEDUCATION: 5thstd .OCCUPATION:Labour workADDRESS:Bavaji no delo,nearsanatanashram,S.G.highway,Ahmedabad.DIAGNOSIS:Oesophagus carcinomaHEIGHT: 152CmWEIGHT: 54Kg
PRESENTING COMPLAINS:Patient having complained of following:-Swallowing difficulti-Nausea-Vomiting-Discomfort in chest-Pain during swallowing-Body ache-Mild fever-ConstipationPRESENT HISTORY:Chetangiri is asymptomatic before 3month the he gradually developed swallowingdifficulty,painduering swallowing, tighteness in the chest, so went to the nearest private hospitalbutsymptoms not relieve than refer to the civil hospital for treatment.PAST HISTORY:PAST MEDICAL HISTORY:Upto 40 years chetangiribhai had not any need for stay in hospitalition for any major illness, heneed symptomatic treatment as per symptoms and relieve the symptomsPAST SURGICAL HISTORY:
Before two month he had done oesophageal biopsy for the swallowing difficulty in the civilhospital and finally diagnose the oesophageal carcinoma .DIET HISTORY:Chetangiri’s family is vegetarian so hisfamily eats vegetarian diet. His wife cookedall type of vegetarian diet and sometimes he eat raw vegetables with fruit.He drinkvery hot tea in the day three to four times.PERSONAL HISTORY: Diet : vegetarian & taking all type of small amount diet Appetite : Decreased Sleep :disturb Micturation : No burning micturation Bowel habit: Abnormal habits Smoking : 1 pack bidi in day Alcohol : Some times Drugs : No Tobacco : Sometimes No any other habitsFAMILY HISTORY:In his family no any family members have history of any Hypertension, Diabetes mellitus,Ischemic heart disease, Epilepsy, Asthma, Storks, Arthritis, Cancer or any other disease.Sr. Name of Family Age in Relationship Education OccupationNo. Members Year With patient 1 ChetangiriDevgiri 40Yrs. patient 5th Labour worker Goswami 2 AlkagiriGoswami 35Yrs wife 2nd pass Housewife with labour work
3 ShivgiriGoswami 25Yrs Son 7th pass Labour work 4 RajangiriGoswami 24Yrs Son’s wife 7th pass Housewife 5 SangitaGoswami 10Yrs Grand 4thstd - daughter 6 RamangiriGoswam Yrs Grand son 1st - iSOCIOECONOMIC HISTORY :In his family all family member are labour worker so his family’s income is not good they earnand eat daily and not store adequet stock for diet .they eat routine diet such as roti,rice ,sometimes green vegetables, potetoes more used, once in week they cooked dal. There is no anyadequatefacallity in his house also.PHYSICAL EXAMINATIONVITAL SIGNDate Temp ( Pulse Respiration(/min) BP (mm of F) (/min) Hg)18-7- 99 F 90/min 20/min 120/74201219-7- 98.4 F 9o/min 22 min 118/64201220-7- 98.6 F 100/min 22 min 116/78201221-7- 98.6F 96/min 24 min 118/74201222-7- 98.4 F 100/min 20 min 120/702012GENERAL 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: 152cm Weight: 52kgSKIN 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 light
EAR: 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 ,dirty 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: Crab herd with stethoscope 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 present
Genital and rectum: No enlarged inguinal lymph nodes, No hemorrhoids, no enlargement of prostate glands. Bladder & Bowel Pattern: AbnormalINVESTIGATIONSerum Biochemistry test: Investigation In patient Normal valueHemoglobin 14 % gm% 14 – 17 gm %.RBC 98 mg/dl 153mg/mlUREA 18.34 mg/dl 15-45mg/dlWBC 8000/cumm 4000-11000/cummS.creat. 0.85mg/dl 0.7-1.5mg/dlSGPT 48U/L 0-55U/LS. Alkpo4 68U/L <50-150U/LS.Billirubin 0.7mg/dl 0.2-1.2mg/dlBLOOD CHEMISTERYFASTING 96.0mg/ dl 70-110mg/dlX-RAY CHEST:-Both cp angles appear clear-Heart size &aorta appear within normal limits-Rest of bony thorax under vision appear normal.ECG: wnlBiopsy-Finding-There is circumferential,ulcerative proliferative growth starting ,extending upto 33cms.MEDICATION-Injection amikasine 500gm i/v 12hourly.-Injection diacloran 1 ampoule i/m sos.
- Injection Rantac 1 ampouls i/v 12 hourly.- Injection Glucose 5% 1 litre i/v slowly. 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 CONDITION ANATOMY AND PHYSIOLOGY OF OESOPHAGUS-- The adult esophagus is a 25 cm-long tube and is fixed superiorly at the cricopharyngeusmuscle, which is considered as the upper esophageal sphincter.- Esophagus courses inferiorly through the posterior mediastinum behind the trachea and theheart and exits the thorax through the hiatus of the diaphragm.- The so-called lower esophageal sphincter (LES) is not a true anatomic sphincter, but rather afunctional one.- Tonic muscular contraction at the lower end of the esophagus creates an action similar tothat of a one-way flutter valve.- The transition from the normal squamous mucosa of the esophagus to the gastric mucosa atthe esophago-gastric junction occurs abruptly at the level of the diaphragm.- The venous drainage of the esophagus is important in portal hypertension because it formsesophageal varices.- The functions of the esophagus include:i) Esophagus conducts food and fluids from the pharynx to the stomach andii) Prevents reflux of gastric contents into the esophagus.- These functions require coordinated motor activity including both extrinsic and intrinsicinnervation, myogenic properties and humoral substances.Clinical features of esophageal dysfunction include:1. Dysphagia- is the difficulty in swallowing due to mechanical and functional disorders.2. Heartburn- is the retrosternal burning pain. It is usually due to regurgitation of gastriccontents into lower esophagus.
3. Hematemesis- is the vomiting of blood due to inflammation or ulceration or rupture ofblood vessels.DEFINITION-Esophageal cancer (or oesophageal cancer) is malignancy of the esophagus. There are varioussubtypes, primarily squamous cell cancer andadenocarcinoma , Squamous cell cancer arisesfrom the cells that line the upper part of the esophagus. Adenocarcinoma arises fromglandular cells that are present at the junction of the esophagus and stomach.CAUSES:In Book In Patient NoBarretts esophagusHeredity NoAge is another critical factor NoA man with a personal history of cancer NoLifestyle and Dietary Causes due to obesity NoTobacco smoking YesHuman papillomavirus (HPV) YesPlummer-Vinson syndrome (anemia and esophageal May bewebbing)Tylosis and Howel-Evans syndrome NoAchalasia NoPATHOPHYSIOLOGY:
The progression of Barrett metaplasia to adenocarcinoma is associated with several changes ingene structure, gene expression, and protein structure.The oncosuppressor gene TP53 and various oncogenes, particularly erb -b2, have been studiedas potential markers.Casson and colleagues identified mutations in the TP53 gene in patients with Barrettepithelium associated with adenocarcinoma.alterations in p16 genes and cell cycle abnormalities or aneuploidy appear to be some of themost important and well-characterized molecular changes. However, the exact sequence of events in the progression of Barrett esophagus toadenocarcinoma is not known. Probably multiple molecular pathways interact and areinvolved.o Allelic losses at chromosomes 4q, 5q, 9p, 9q, and 18q and abnormalities of p53, Rb, cyclinD1, and c-myc have been implicated.CLINICAL MENIFESTATION:In Book In PatientDysphagia (difficulty swallowing) Presentodynophagia (painful swallowing) PresentPain behind the sternum or in the Presentepigastriumcoughing and an increased risk of aspiration Not Presentpneumonia.nausea and vomiting Presentupper airway obstruction Not present
superior vena cava syndrome. Not PresentThe tumor surface may be fragile and Not Presentbleed, causing hematemesislung metastasis could cause shortness of Not Presentbreath, pleural effusions PresentASSESSMENT & DIAGNOSTIC FINDINGS:IN BOOK IN PATIENT - Taking a thorough history - Done including family history - Physical examination - Done - microscopic analysis of the - Done biopsy - Laboratory work (cholesterol - Done levels, glucose ) Biopsies - Done Computed tomography (CT) - Not DonePositron emission tomography - Not DoneEsophageal endoscopic ultrasound - Not doneMANAGEMENT: Esophageal cancer affecting the lower esophageus. Insets show the tumor in more detail both before and after placement of a stent. The treatment is determined by the cellular type of cancer (adenocarcinoma or squamous cell carcinoma vs other types), the stage of the disease, the general condition of the patient and other diseases present. On the whole, adequate nutrition needs to be assured, and adequate dental care is vital. If the patient cannot swallow at all, an esophageal stent may be inserted to keep the esophagus patent; stents may also assist in occluding fistulas. A nasogastric tube may be necessary to continue feeding while treatment for the tumor is given, and some patients require a gastrostomy (feeding hole in the skin that gives direct access to the stomach). The latter two are especially important if the patient tends to aspirate food or saliva into the airways, predisposing for aspiration pneumonia.
Esophagectomy is the removal of a segment of the esophagus; as this shortens the length of the remaining esophagus, some other segment of the digestive tract (typically the stomach or part of the colon or jejunum) is pulled up to the chest cavity and interposed. If the tumor is unresectable or the patient is not fit for surgery, palliative esophageal stenting can allow the patient to tolerate soft diet.SURGICAL MANAGEMENT: The thoracoabdominal approach opens the abdominal and thoracic cavities together. The two-stage Ivor Lewis (also called Lewis-Tanner) approach involves an initial laparotomy and construction of a gastric tube, followed by a right thoracotomy to excise the tumor and create an esophagogastric anastomosis. The three-stage McKeown approach adds a third incision in the neck to complete the cervical anastomosis A fourth method of EMR employs the use of a clear cap and prelooped snare inside the cap. After insertion, the cap is placed on the lesion and the mucosa containing the lesion is drawn up inside the cap by aspiration. The mucosa is caught by the snare and strangulated, and finally resected by electrocautery. This is called the "band and snare" or "suck and cut" technique. Although most lesions treated in the esophagus have been early squamous cell cancers, EMR can also be used to debulk or completely treat polypoid dysplastic or malignant lesions in Barrett’s esophagus. Laser therapy is the use of high-intensity light to destroy tumor cells; it affects only the treated area. This is typically done if the cancer cannot be removed by surgery. The relief of a blockage can help to reduce dysphagia and pain. Photodynamic therapy, a type of laser therapy, involves the use of drugs that are absorbed by cancer cells; when exposed to a special light, the drugs become active and destroy the cancer cells. MEDICALMANAGEMENT Chemotherapy depends on the tumor type, but tends to be cisplatin-based (or carboplatin or oxaliplatin) every three weeks with fluorouracil (5-FU) either continuously or every three weeks. In more recent studies, addition of epirubicin was better than other comparable regimens in advanced nonresectablecancer.Chemotherapy may be given after surgery (adjuvant, i.e. to reduce risk of recurrence), before surgery (neoadjuvant) or if surgery is not possible; in this case, cisplatin and 5-FU are used. Ongoing trials compare various combinations of chemotherapy; the phase II/III REAL-2
trial – for example – compares four regimens containing epirubicin and either cisplatin or oxaliplatin, and either continuously infused fluorouracil or capecitabine. Radiotherapy is given before, during or after chemotherapy or surgery, and sometimes on its own to control symptoms. In patients with localised disease but contraindications to surgery, "radical radiotherapy" may be used with curative intent.NURSING 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. .Altered body temperature due to presence of infection. 2. Imbalance nutritional level less than body requirement related to loss of appetite. 3. Activity intolerance related to surgery done. 6 Impaired body image due osurgeory. 7 Alteredself image and confidence due to fegure. HEALTH TEACHING: Arrange specific services for patient(e.g. respiratory therapy education, physical therapy for exercise & breathing) Explain patient’s reletives about discharge planning. Give advice about regular medication as per timing. Explain and demonstrate about chest physiotherapy by doing deep breathing exercise . Explain and demonstrate about coughing and how to remove cough. Advice given about good nutritive . Advide given for prevention of infection management.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.respiratory disease.org/.com.in - http://www.google.com. - http://www.medicine.com.