Name: J.D.D.Age: 80Sex: MaleCitizenship: FilipinoCivil Status:WidowReligion: Roman CatholicDate and Time admitted:12/12/11, 1:30 pmWard:Chief Complaint: Hypogastric andinguinal painAttending Physician: Dr. R.Date of last admission: 11/06/11
Malignant MelanomaIs a rare form of skin cancer that arises frommelanocytes, usually in preexisting mole. Amole is an aggregation, or “nest” ofmelanocytes. The melanoma can appear as alarge, flat, spreading lesion or a deeplypigmented nodule.
•Congenital Nevi-Congenital nevi are present at birth. Some lesions aresmall; others are large enough to cover an entire body area. Thecolor can range of brown to black.•Dysplastic Nevi-Are also called atypical moles. This are not present atbirth, they appear as normal nevi during childhood and becomedysplastic (having abnormal development) after puberty.•Lentigo Maligna-Also called Hutchinson’s freckle, is a tan or black on theskin that looks like a freckle. It grows slowly, becoming mottled,dark, thick, and nodular. It usually seen on one side of the face ofan older adult who has had a large amount of sun exposure
•Superficial spreading melanoma-most common type-the lesions usually flat and scaly or crusty and about 2cmin diameter.-found in trunk and back of men and on the legs of women-median age of occurrence is the 50’s
•Lentigo maligna melanoma-often arises from the precursor lesions, lentigo maligna-least serious form-it occurs in skin that has had long-term sun exposuresuch as face, neck, and sometimes the dorsal surface ofthe hands and lower extremities.-affected more in women than men.•Nodular Melanoma-are raised-shaped blue black or red nodules on areas ofthe head, neck and trunk that may or noy may exposedto the sun.-looks like blood blister, or they may ulcerate and bleed.
•Acral Lentiginous-also called mucocutaneous melanoma, is less commonwith people with fair skin and more common in peoplewith dark skin.-occurs in palms of the hands, soles of the feet, themucous membrane and the nailbeds.-common in ages 50’s and 60’s.
Limited range of motion Poor skin turgor hypotension complaints of painAssessing the ABCD’s of molesAssymetryBorder: uneven borderColor: many colorrs (brown, red, black, blue, pink)Diameter: moles greater than 6 mm (larger than theeraser on a pencil)
•UV rays•Risk factors:-excessive exposure to light-fair complexion-personal or family history of melanomaincreased age, particularly older than age 60-preexisting multiple mole, atypical nevi, or achanging nevus
•Relieving pain and comfort•Prevent complication particularlymetastasis to the lungs, liver or brain
Medication Non-medicationAdminister Analgesic(tramadol) and Non-steroidal anti-inflammatory drug(Etoricoxib)•Monitor V/S•Monitor I/O•Assess the changes inexisting moles ordevelopment of a newpigmented skin lesions.
Sign and Symptoms Nursing DiagnosisHypotension>3 second capillary refillImpaired skin integrity relatedto destruction of skin•Inability to maintain usualroutines, Limited ROM•Lethargy•Verbal report of FatigueActivity intolerance related toweakness from cancer•Partially Hearing loss•Impaired speechImpaired VerbalCommunication related todegenerative changes
Sign and Symptoms Nursing Diagnosis•Change in bowel pattern•Decrease frequency of stoolConstipation related toside effects of medication•Verbal report of pain on theaffected areaAcute pain related todisease process
Nursing Problems Interventions ExpectedOutcomes•Change in bowelpattern•Decrease frequencyof stool•Encourage increasefluid intake•Consult withdietitianThe patient willmaintain normalpattern of bowelfunctioning•Immobility andprone to fall.•Encourage use ofside rails of bed•Instruct the familynot to leave thepatient unattendedThe patient willpromote safety andsecurity
NursingCompetenciesNursing ActivitiesSafe and QualityNursing CareDo not leave the patient unattendedUse side rails of bed to prevent fallCommunication Establishes rapport with client and familyUse therapeutic communicationUse alternative method of communicationCollaboration &TeamworkEstablishes collaborative relationship withcolleagues and other members of thehealth teamHealth Education Give accurate and precise informationdisseminationLegal Responsibility Documents care rendered to clients
Nursing Competencies Nursing ActivitiesEthico-moral responsibility Provide Privacy and confidentialityPersonal and ProfessionalDevelopmentProjects a professional image ofthe nurseRecord Management Record precise and accurate.Write legibly and neat.Management of resources andenvironmentKeep the environment clean andprovide the necessary resourcesfor emergency casesMaintain the proper functioning ofthe equipmentQuality improvement Gathers data for qualityimprovementResearch Applies research findings in nursingpractice