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Introduction

Cancer begins when cells in the body become abnormal and multiply without control or order. These cells form a growth of tissue, called a tumor. A tumor can be benign (noncancerous) or malignant (cancerous).

Nasopharyngeal cancer (also called nasopharyngeal carcinoma or NPC) is a disease of the nasopharynx, which is the air passageway at the upper part of the pharynx (throat) behind the nose. The pharynx is a hollow tube approximately five inches long that starts behind the nose and ends on top of the larynx (or voice box) and esophagus (the swallowing tube that goes

from the throat to the stomach). The nostrils lead through the nasal cavity into the nasopharynx and an opening on each side of the nasopharynx (called the Eustachian tube opening) leads into the middle ear on each side. There are several types of benign nasopharyngeal tumors, including angiofibromas and hemangiomas that involve the vascular (blood-carrying) system and tumors in the lining of the nasopharynx that include the minor salivary glands.

According to the World Health Organization (WHO), NPC is classified into three subtypes: Keratinizing squamous cell carcinoma (WHO type 1), Nonkeratinizing squamous cell carcinoma (WHO type 2), Undifferentiated or poorly differentiated carcinoma, including lymphoepithelioma and anaplastic variants (WHO type 3). Many types of nasopharyngeal cancer contain white blood cells, and these lymphocytes give it the name of lymphoepithelioma. 

EBV (Epstein-Barr virus) NPC is the most common epithelial cancer in adults. The detection of nuclear antigen associated with Epstein-Barr virus (EBNA) and viral DNA in NPC type 2 and 3, has revealed that EBV can infect epithelial cells and is associated with their transformation. The etiology of NPC (particularly the endemic form) seems to follow a multi-step process, in which EBV, ethnic background, and environmental carcinogens all seem to play an important role. Lo et al. showed that EBV DNA was detectable in the plasma samples of 96% of patients with non-keratinizing NPC, compared with only 7% in controls.More importantly, EBV DNA levels appear to correlate with treatment response and they may predict disease recurrence, suggesting that they may be an independent indicator of prognosis. In adults, other likely etiological factors include genetic susceptibility, consumption of food (in particular salted fish) containing carcinogenic volatile nitrosamines, and Exposure to chemical agents i.e. tobacco, drugs, and plant

products.

This case was a case of PT.A1, 46 years old from Basilan. Sulu, who is positive smoker and drinker for almost 20 years, who diagnosed with cancer last october 16, 2011 and confirmed diagnosis of nasopharyngeal carcinoma, differentiated Non-keratinizing type 4 (T1,N3,M0), ptb tx completed.

I. Health HistoryPatient Profile Data:

Name: PT. A1

Age: 46 yrs. Old

Address: Basilan, Jolo Sulu

Sex: Male

Date of Birth: March 22, 1965

Place of Birth: Basilan, Mindanao

Race/Religion: Muslim

Marital Status: Married

Education: College, (Undergradute)

Occupation: Military Servant for 22years

Chief Complain:

“Dysphagia, body weakness and pain on the necks and joints, productive cough and vomiting”

Present History:

Patient was admited last September 22, 2010, seven months prior to admission patient noted a palpable mass on the right lateral neck with no accompanied sign and symptoms only complained of dysphagia and hoarseness. The month after the mass gradually increases in sized, patient refused tohave further evaluation and management. August 15 of 2010 patient undergo biopsy of lateral neck and revealed that no malignant cell seen.after a month hard mass gradually increasing and punch biopsy was done which revealed positive for squamous carcinoma, differentiated, non keratinizing, then they decided to transfer the patient to Oncology department for radiotherapy.Last May 31, 2011 patient again undergo a biopsy procedure and revealed positive for multiple neck mass which is firm, non-tender and fixed. Patient also undergo nasopharyngolarygoscopy last June 29,2011 which revealed a positive mass bulging the nasopharyngeal are that cause positive drooling of saliva and positive paresis of right vocal cord. And in the latest biopsy done last June 23, 2011 revealed positive for

metastatic carcinoma, undifferentiated 2.2 cm in widest diameter. His wound in lower extremities is positive for fungal organisms.

Past History

The patient cannot recall his common childhood illness. He doesn’t have diabetes milletus, heart problem and hypertension but he had been diagnosed to have pulmunary tuberculosis last September 1, 2010 and he is able to complete his medication regimen. He denies any allergies on foods and medication; he doesn’t have injury and fructures in previous years. He doesn’t undergo any surgical operation, aside from the invasive procedure he go throug in past months.

Family History

The patient doesn’t have any family history of hypertension, diabetes milletus, asthma and cancer.

Health management History

Before the patient has beed hospitalized he smokes 60 packs per year and drinks alcohol, he cannot eats without condiments such as fish sauce or soysauce. He is also fun of drinking coffee, always in the morning and in the afternoon.And he always eats on time.

Home environment and Psychosocial History

They have one storey house, they lived in rural community, and the mode of transportation was tricycle and motor bike. They are far from market but near on Hospitals and churches. Their religion was Muslim and they go to their church once a week.

His perception to his self was a strong man because he is the one who works for his family, and he doesn’t have any source of stress until he had the disease. If he wills able experience stress, he will read newspapers or watch television and smoke ciggaretes as his coping mechanism. His perception to his present illness, after the hospitalization he always hope that he will be fine and free from cancer, but as time goes by he feels body weakness and pains that causes his anxiety, he always prays and hoping for wellness.

II. Gordon’s Functional Health History:

Health Perception/ Health Management:The patient complies with medication; he took his medication on time. He also

experiences anxiety because of pain and his body wekness.

Nutritional-MetabolicHe had feed throug parenteral nutrition, but he keeps and trying to feed his self

through mouth even though he experienced difficulty of swallowing. Elimination

His elimination is regular, sometimes twice a week and his urination was 2 times a day.

Activity– ExercisePatient does not exercise and all vital signs are within the normal except for the

pulse rate, he had tachycardia.

Cognitive and PerceptualPatient has 20/20 vision. Hearing is not that good because of mass in

nasopharynx, difficulty of swallowing is noted, and smell is good. Pain management; complained of pain 6/10 in pain scale. Cognitive functioning well.

Sleep & RestPatient’s had sleep difficulty because of pain; he usually woke up during dawn. He sleeps 6hrs hours a day. His sleeping pattern was 9:00 pm- 3:00am or sometimes 5:00am. Then he takes a nap when he doesn’t experienced pain.

Self-perception / Self-conceptPatient’s has difficulty in speaking, he had hoarse voice and eyes perceive little optimism. Body posture is good.

Role-relationshipPatient stress satisfaction with his partner and family, however patient perceives

hospitalization alters he’s father-role within the family for his family is in Mindanao.

Coping/Stress ToleranceWhenever had stress in the family, he will watch television or reading newspaper

and smoke cigarretes as a coping mechanism.

Values-Belief

He is a Muslim and he usually go to church once a week together with his family and stops when he was been hospitalized but he keeps on praying every night.

III. Review of the systemAnatomy and Physiology

The nasopharynx is the upper portion of the pharynx (the tube at the back of the throat), and it lies just above the soft palate in the mouth. The nasopharynx is an important passageway that allows air to travel from the nose into the windpipe (trachea) and food into the foodpipe (esophagus). Located on the back wall of the nasopharynx are the pharngeal tonsils, also called the adenoids, which are a network of immune system cells that defend the mucus membranes of the mouth and airways. The nasopharynx also plays a role in hearing because openings at the side of pharynx connect the hearing tube to each ear.

Pathophysiology:

The precipitating factor that causes nasopharyngeal carcinoma is presence of EBV or Epstein-Barr virus. Secondary was eating of salted-prevervatives food in early childhood, smoking, alcohol abuse and other exposure to sun and a chemical that causes formation of benign bronchial epithelium tissue that transform into neoplastic tissue which is called nasopharngeal carcinoma. It has different types and one of this is squamous cells that irritates and causes obstruction of airway. When it is happens there is presence of sputum production and wheezing that leads to shortness of breath and chronic cough, on the other hand when obstruction happens because of bulging of mass in the nasopharyngeal area that causes

compresion in the surrounding organs and irritation of the laryngeal nerves which causes hoarseness of voice. Because of the compression of esophagus, dysphagia happens. Further destruction of the organs happens that causes drooling os saliva and paresis of the part of vocal cords.

Pathophysiology

Precipitating Factor:

herpesvirus 4 (HHV-4), is a virus of the herpes family, which includes herpes simplex virus 1 and 2, and is one of the most common viruses in humans.

Precipitating Factor:

Eating salt-preservatives foods (fish eggs, leafy vegetables and roots) during early childhood.

Cigarrete smoking Alcohol abuse Poor oral hygine Long term exposure to sun Occupational

Formation of benign bronchial epethelium tissue.

Transformation of benign tissue into neoplastic tissue Nasopharyngeal

cancer

Squamous cell carcinoma

Irritation and obstruction of airway

Sputum production and wheezing

Shortness of breath and chronic cough

Mass bulging the nasopharyngeal area

Irritation of the laryngeal nerve

Compression of the surrounding organs (esophagus, vocal cords and

salivary glands)

-Difficuly of swallowing-drooling of saliva

-paresis of right vocal cord

Hoarseness of voiceAnorexia

Weight loss

IV. Laboratory Findings:

1. Biopsy of lateral neck

 Is a medical test involving the removal of cells or tissues for examination, It is the medical removal of tissue from a living subject to determine the presence or extent of a disease. The tissue is generally examined under a microscope by a pathologist, and can also be analyzed chemically.

Result: (June 23, 2011) latestPositive for metastasic carcinoma, undifferentiated, 2.2 cm in widest

diameter.Interpretation: Abnormal

In the normal anatomy, there should be no presence of abnormal cell.

2. Nasopharyngolaryngoscopy

A diagnostic medical procedure that uses a flexible fibre-optic endoscope to visualize the structures inside the nasal passages, including the sinus openings, the larynx and the vocal cords.

Result: (June 29, 2011)

Positive bulging mass nasopharyngeal area

Positive drooling of saliva

Positive paresis, right vocal cords.

Interpretation: Abnormal

Because of the bulging mass, surrounding organs are affected that causes paresis and abnormal function of it.

3. Computerized tomography scanPictures of structures within the body created by a computer that takes

the data from multiple X-ray images and turns them into pictures on a screen. CT stands for computerized tomography. The CT scan can reveal some soft-tissue and other structures that cannot even be seen in conventional X-rays. Using the same dosage of radiation as that of an ordinary X-ray machine, an entire slice of the body can be made visible with about 100 times more clarity with the CT scan.

Result: (November 12, 2011)Diffuse nasopharyngeal mucosal thickening more on right side.Multiple severely enlarge lymphoids on both side of the neck, larger on

right.Multiple enlarge lymphnodes on axilla, mediastinum and ride illeum.

Interpretation: AbnormalThere should be no palpable lymph nodes; presence of it indicates

inflammation of body part or alteration on function of body part.4. The complete blood count (CBC) The complete blood count is the calculation of the cellular (formed elements)

of blood. These calculations are generally determined by special machines that analyze the different components of blood in less than a minute.A major portion of the complete blood count is the measure of the concentration of white blood cells,red blood cells, and platelets in the blood.

Result: (August 04, 2011)Hgb: 10.1 g/dl NV: 14.0-16.5 g/dlHct: 0.29 g/dl NV: 0.40-0.50 g/dlRBC: 3.42 x 106 /udL NV: 4.2-5.4 x 106 /udL WBC: 3.27 x 106 /udL NV: 4.4-11.3 x 106 /udL

Interpretation: Abnormaldecreased in Hgb, Hct, RBC, WBC indicates blood problems like

anemia.5. Blood chemistry test

Is divided into groups of basic blood tests that give specific information about the condition of your organs. The tests are grouped according to body functions including metabolism, drug absorption, blood circulation and body fluid balance.

Result: (August 04, 2011)Crea: 0.7 mg/dl NV:  0.6-1.2 mg/dl -within the normalSGOT: 20-25u/L NV:  5-40 U/L –within the normalSGPT: 29u/L NV: 7-56 U/L – within the normalTotal protein: 30-46g/dl NV:  60-85g/dl -abnormal

Albumin: 2.7g/dl NV: 3.4 - 5.4 g/dl –abnormalAG/ratio: 1.40 NV: 1.7-2.2- within normalGlobulin: 19-30 mg/dl NV: 75 to 300 mg/dL -abnormalSodium: 132.0 mEq/L NV: 135 to 145 mEq/L - abnormalPotassium: 3.16 mEq/L NV: 3.7 to 5.2 mEq/L. - within normal

Interpretation: decreased total protein and albumin indicates edema or water retention while decreased total protein indicates malnutrition or malabsorption, decreased globulin may indicates the kidney does not filter the protein from the blood and it leaks into the urine. Low total body water and sodium levels may be due to dehydration, vomiting, diarrhea, over diuresis, or ketonuria.

6. Sputum microscopy

A sputum sample is obtained by coughing deeply and expelling the material that comes from the lungs into a sterile cup. The sample is taken to a labarotory and placed in a medium under conditions that allow the organisms to grow. A positive culture may identify disease-producing organisms that may help diagnose bronchitis, tuberculosis, a lung abscess, or pneumonia.

Result: (August 4, 2011)725 puss cells, <25 epithilial cell gm(-) bacillus-feus

Interpretation: Abnormal Moderate growth of klebsiella pneumoniae

7. Wound culture testA wound culture is a diagnostic laboratory test in which

microorganisms—such as bacteria or fungi from an infected wound, are grown in the laboratory on nutrient-enriched substance called media—then identified. Wound cultures always include aerobic (with oxygen) culture, but direct smear evaluation by Gram stain and anaerobic (without oxygen) culture are not performed on every wound.

Result: (July 27, 2011)KOH-postive for fungal elements

Interpretation: Abnormal

V. Drug Study

Drug’s name Action Indication Contraindication

Adverse Reaction

Nursing Intervention

Ketorolac

Brand name:Remopain

Classification :

NSAIDs

Analgesic, anti- inflammatory and antipyretic. Inhibits prostaglandin synthesis by inhibition of cyclo-oxygenase enzyme. It also inhibits leukotriene synthesis, help stabilize lysosoma; membranes and exert anti- bradykinin activity.

Short term management of moderate to severe post-operative pain.

Active peptic ulcer disease, recent gastrointestinal bleeding or perforation, moderate to severe renal impairment, hypovolemia.

Gastrointestinal ulceration, bleeding, perfusion, post-operative bleeding, acute and renal failure and liver failure

Assess pt’s pain before and 1hr after treatment: type, location, intensity and ROM.

Monitor for adverse reaction: CNS, drowsiness, insomia and syncope.

Assess for Gi bleeding: blood in sputum, stool and emesis.

Give with food or milk to decrease

gastric symptoms.

Drug’s name Action Indication Contraindication

Adverse Reaction

Nursing Intervention

tramadol

Brand name:Tramadol HCL

Classification :

Opiates and anatgonist

Centrally acting analgesic not chemically related to opoids but binds to mu-opoid receptors and inhibits reuptake of norepineprhine and serotonin

Moderate to severe pain.

Hypersensitivity. Acute intoxication with alcohol, hypnotics, centrally acting analgesic, opoids or psychotropic agents.

Vasodilatation, dizziness, vertigo, headache, somnolence, stimulation, anxiety, confusion, coordination disturbances, euphoria, nervousness, sleep disorder, seizures.

Assess pt’s pain before and regularly thereafter treatment to monitor drug effectiveness.

Monitor for adverse reaction: CNS, dizziness, vertigo, headache, somnolence and anxiety.

Monitor intake and output and check for decreasing output may indicate retention.

Assess changes in bowel pattern, increase diet

bulk and oral fluids to prevent constipation

Drug’s name Action Indication Contraindication

Adverse Reaction

Nursing Intervention

Ampicillin

Brand name:Ampicillin trihydrate

Classification :

penicillins

Interfers with cell wall synthesis of susceptible organisms, preventing bacterial multiplication, it also renders the cell wall osmotically unstable and burst due to osmotic pressure. Deactivated by beta-lactamase, an enzyme produced by resistant bacteria.

Treatment of respiratory tract and soft tissue infections, bacterial meningitis, septicema and gonococcal infections caused by susceptible microorganisms

Hypersensitivity to penicillins, cephalosphorinsor impenem.

Thrombophlebitis at injectionsite, dizziness, fatigue, insomia, reversible hyperactivity, nuerotoxicity.

Obtain pt history of infection before and during the therapy and assess response.

Assess pt for sign and symptoms of infection

Assess for allergic reactions.

Obtain c & s before drug therapy.

Monitor renal function.

Drug’s name Action Indication Contraindication

Adverse Reaction

Nursing Intervention

Fluconazole

Brand name:flucoral

Classification :

Antifungals

Inhibits fungal CYP, an enzyme responsible for fungal steroid synthesis, and weakens fungal cell wall.

Oropharyngeal and esophageal candidiasis; vaginal candidiasis; prevention of candidiasis in bone marrow transplant; cryptococcal meningitis.

Hypersensitivity to fluconazole, other azole antifungals. Co- administration with cisapride and terfenedine.

Headache, seizures, rash, exfoliative skin disorder, nausea, vomiting, abdominal pain, diarrhea, leukopenia and thrombocytopenia.

Assess for sign and symptoms of infectio: obtain c&s baseline and during treatment.

Monitor hepatotoxicity: increased AST, ALT, alkaline phosphate, bilirubin; drug will be discontinued if it is occurs.

Monitor possible adverse reaction.

Drug’s name Action Indication Contraindication

Adverse Reaction

Nursing Intervention

Mupirocin

Brand name:bactroban

Classification :

Antibacterials

Binds to bacterial isoleucyl transfer RNA synthetase, which results in inhibition of bacterial protein synthesis.

Topical treatment of impetigo, folliculitis, furunculosis, ecthyma, infected dermatoses.

Hypersensitivity. Not for opthalmic use.

Localized burning, stinging and itching.

Document indication for therapy including type, onset, duration and characteristics of symptoms.

Obtain c & s before drug therapy.

Assess for allergic reaction.

Monitor for possible drug induced adverde reactions.

Drug’s name Action Indication Contraindication

Adverse Reaction

Nursing Intervention

Metroclopramide

Brand name:plasil

Classification :

Antiemetics

Dopamine antagonist that acts by increasing receptor sensitivity and response of upper GIT tissues to acetylcholine.

Gastrointestinal motility disturbances. Nausea and vomiting of central and peripheral origin associated with surgery, metabolic disease, malignant disease, infectious diseases and drug induced.

Phaeochromocytoma. Pt in whom increased gastrointestinal motility might be dangerous, presence of GI hemorrhage, mechanical obstruction or perforation.

Sedation, restlessness, lassitude, fatigue, diarrhea, insomia, headache, dizziness, nausea.

Assess Gi complains: nausea, vomiting, anorexia, constipation.

Frequent monitor blood pressure.

Assess for adverse reaction.

Monitor for possible drug induced adverde reactions.

Drug’s name Action Indication Contraindication

Adverse Reaction

Nursing Intervention

Omeprazole

Brand name:omeprazole

Classification :

Proton pump inhibitors

Supressess gastric secretion by inhibiting hydrogen/potassium ATPase enzyme system in the gastric parietal cell characterized as a gastric acid pump inhibitor since it blocks the final step of acid production.

Short-term treatment of active duodenal ulcer, gastroesophageal reflux diseas, inluding erosive esophagitis and symptomatic GERD.long treatment of pathologic hypersecretory conditions.

Hypersensitivity. Lactation and children. Combination therapy with clarithmycin should not be used in patient with hepatic impairment.

Angina, tachycardia, bradycardia, palpitation, headache, dizziness, rash and diarrhea.

Assess other medication that pt taking for effectiveness and interactions.

Monitor therapeutic effectiveness and adverse reactions at beginning of therapy and periodically throughout.

Assess for GI system

Monitor for

hepatic enzymes

Drug’s name Action Indication Contraindication

Adverse Reaction

Nursing Intervention

Prednisone

Brand name:prednisolone

Classification :

Adrenocorticosteroid hormones

Glucocorticoid with minimal mineralocorticoid activity. The anti-inflammatory effects may be due to inhibition of prostaglandin synthesis.

Used as an anti-inflammatory of immunosupressant agent. Allergic reaction, selective tissue and muscle disorders, some cases of rheumatoid arthriti.

Patient with osteoporosis, active peptic ulcer, psychoses, systemic fungal infections, acute infections unless effective specifi concurrent therapy can be administers.

Glaucoma with optic nerve damage, loss of visual acuity delayed wound healing, thromboembolism or fat embolism.

Assess pt’s condition before therapy and regularly thereafter to monitor drug effectiveness.

Obtain baseline weight, blood pressue and electrolytes levels.

Assess for adverse reaction.

Monitor BP every 4hrs, pulse notify physician if chest pain occurs.

Drug’s name Action Indication Contraindication

Adverse Reaction

Nursing Intervention

GENERIC NAME:CyanocobalaminVitamin B12

BRAND NAME:Cyanocobalamin

CLASSIFICATION:Nutritional drugs –Vitamins and Minerals

Coenzyme that stimulated metabolic function needed for cell replication, hematopoiesis, nucleoprotein and myelin synthesis

RDA for cyanocobalamin-Vitamin B12 defiency from inadequate diet, subtotal gastrectomy, other conditions, disorder or

Patients who are hypersensitive to Vitamin B12 or cobalt and in those with early Leber’s disease

None reported Stress importance the Vitamin supplement

Teach  healthy dietary habits

Instruct client not to take folic acid to replace vitamin B12, as it

disease except malabsorption r/t pernicious anemia or GI diseas

may accelerate hematologic manifestations

Sensitivity tests/ intradermal  test should be done for those with possible sensitivity

Do not mix with other parenteral preparations in same syringe drugs

Drug’s name Action Indication Contraindication

Adverse Reaction

Nursing Intervention

N-Acetylcysteine

Acetylcysteine splits linkage of mucoproteins.

Acetylcysteine is used in adjunct

Hypersensitivity Stickiness on

face Assess

pretreatment respirations

Classification :

Respiratory and intratracheal inhalant, Mucolytic, and an Antidote.

It reduces the viscosity of pulmonary secretions, facilitates removal by coughing, postural drainage, mechanical means. Acetylcysteine protects against acetaminophen overdose-induced liver toxicity.

treatment for abnormally viscid mucous secretions present in acute and chronic bronchopulmonary disease and pulmonary complication of cystic fibrosis, tracheostomy care and in treatment of acetaminophen overdose. It is also used in the prevention of renal damage from dyes given during certain diagnostic tests like CT scan.

Transient unpleasant odorIncreased bronchial secretions,Irritated throatNauseaand VomitingRhinorrheaSkin rashFacial edemaBronchospasmWheezing

for rate, depth, and rhythm.

If bronchospasm occurs, stop the treatment and notify the physician.

Monitor rate, depth, rhythm, and type of respiration

Check sputum for color, consistency and amount.

.

VI. Nursing Care Plan

Assessment Diagnosis Planning Implementation Evaluation No subjective cues.

-

Disturbed body image and low self-esteem related to change in appearance (bulging mass on right neck) and altered structure and function.

Assessment Diagnosis Planning Implementation Evaluation No subjective cues. Self care deficit

related to pain and body weakness .

Discharge Plan

Medication

Antiemetic drug (plasil) – for nausea and vomiting side effect of Mucolytic drugs (N- Acetylcysteine) - to reduce pulmunary secretion or

sputum production. Vitamin B – prevention of vitamin B deficiency Proton pump inhibitor (omeprazole)- decreases of gastric secretion due

to the patients is under parental nutrition. Exercise

Walking every morning or encourage the clients to do simple exercise. Teach the relatives to do to the clients the passive and active Range of motion exercise.

Treatment

Comply in medication regimen. Radiotherapy – is the use of high energy x-rays and similar rays (such as electrons) to

treat disease. It works by destroying the cancer cell in the treated area. Avoid exposure to diseases expecially respiratory diseases.

Health Teaching

Importance of meeting of nutritional needs. Avoid salted-preservatives foods. Importance of increasing the immune system, healthy lifestyle and avoid smoking and

decrease alcohol intake. Monitor weight by the relatives. Advise the relatives not to leave him alone, and assist in activities of daily living. Importance of proper hygiene and infection control such as handwashing.

OPD

Comply with follow-up check-up after a week.Diets

Parental nutrition as ordered by physician. Foods hign in vitamin C. 1800 cal. 40-60% non-protein. Increase high fiber diet for enhancement of elimination Increase vegetables and fruits. Take atleast 6-8 glass of water to prevent dehydration.

Spirituality

Always pray for the guidance of God. Don’t lose hope. Support network specially the family.

V.1 General Survey

Name: PT.A1

General survey Normal Findings Actual Findings Analysis

Physical presence

Stated age vs apparent age

The patient’s stated chronological age should be congruent with the apparent

age.

The pt is look like older than his actual

age. He lools 6 years older than his

real age.

Abormal

General appearance Patient should exhibit body symmetry, no obvious deformity, and a well

appearance

Pt.’s body is asymetrical; there is obvious deformity in

his right neck.

Abormal

Body fat Body fat should be evenly distributed.

Fat is evenly distributed to the body. But there is

obvious loss of body fats in the

extremities.

Abormal

Stature Limbs and trunk should appear proportional to body height; posture should be

erect

Limb and trunk should appear

proportional to body height and erect

Normal

Motor activity Gait as well as other body movements should be smooth and effortless

Movement is free and effortless

Normal

Body and breath odors

Normally, there is no apparent odor from patients

Slightly have foul body odor.

Normal

Psychological presence

Dress, grooming, and personal

hygiene

Normally, patients should appear clean and neatly

dressed

Pt. is slightly clean and neatly dressed

up

Normal

Mood and manner Generally, a patient should be cooperative and pleasant

Pt. is annoy and like irritated and

anxious.

Abormal

Speech Patient should response to questions and commands

easily

Pt. cans response through gestures.

Normal

Facial expression Patient should appear awake and alert

Pt.’s active Normal

distress Breathing should be effortless, without cough or

wheezing

Breathing is effortless, with

productive cough

Abormal

Vital sings Normal findings Actual findings analysis

Blood pressure 120/80 mmHg 110/80 Normal

Respiratory rate 12-20 cpm 22 RR slightly increases

Due to productive

cough

Pulse rate 60-100 bpm 132 Abormal

Temperature 36.5-36.4 degree celcius 36.3 Normal

Weight 55kg Normal

Height 165cm Normal

Regions Method Normal findings Actual findings

Analysis

Skin

color

Inspection --- the skin is a uniform whitish pink or brown, depending on the

--skin color is brown

Normal

bleeding, ecchymosis, and vascularity

lesions

moisture

temperature

tenderness

Palpation

patient’s race

-- There are no areas of increased vascularity, ecchymosis or bleeding.

-- no skin lesions should be present except for feckles, birthmarks, or moles(nevi),which maybe flat or elevated.

--normally, the skin is dry with a minimum perspiration.

-- Skin surface should be warm. Hand and feet maybe slightly cooler than the rest of the body.

--no increase in vascularity

--with lesion on lower

extremities

-

--Normally dry

--Skin is warm

--nontender

Normal

Abormal

Normal

Normal

Normal

texture

turgor

edema

-- skin surface should be nontender.

-- skin should normally feel smooth, even, and firm except where there is significant hair growth.

-- when the skin is released, its should return to its original contour rapidly.

-- edema is not normally present.

--smooth skin

--With normal skin turgor

(<3sec)

Presence of edema on both upper and lower

extremities

Normal

Normal

Abormal

Head Inspection

shape of the head

scalp

--the head should be normocephalic and symmetrical.

--the scalp should be shinny, intact, and without

--symmetrical

--shinny and no lesions or

Normal

Normal

face

neck

thyroid gland

lymph nodes

lesions or masses.

--the facial features should be symmetrical.

--the muscles of the neck are symmetrical with the head in a central position.

--thyroid tissue moves up with swallowing but often the movement is so small it is not visible on inspection.

--lymph nodes should not be visible inflamed.

masses

--asymmetrical on right side

--large mass on the both side

larger than right side

Difficult of swallowing

--presence of lympnodes in

bpth axilla midsternum and

illeum

Abormal

Abormal

Abormal

Abormal

Head

Scalp

Palpation --the normal skull is smooth, nontender, and w/o masses or depressions.

--w/o lesions or masses.

--Smooth, non tender, no

masses and depression

--No lesion or masses

Normal

Normal

Mandible

Neck

Thyroid gland

Lymph nodes

-- the temporomandibular joint should articulate smoothly and w/o clicking or crepitus.

--the muscle should be symmetrical w/o palpable masses or spasm.

--no enlargement, masses, or tenderness should be noted on palpation.

--lymph nodes should not be palpable in the healthy adult patient.

-affected by mass,can’t articulate smoothly

--palpable mass on both side much larger than on right

side

With masses

--presence of palpable mass

neck and axilla,medsternu

m and illeum

Abormal

Abormal

Abormal

Abormal

Ears

Auditory screening

Voice whisper test

--the patient should be able to repeat words whispered from a distance of 2 feet.

--able to repeat word, but th pt.hearing is

slightly unclear

--pinkish to

Abormal

External ear

Inspection

palpation

--the ear should match the flesh color of the rest of the patient’s skin and should be positioned centrally and in proportion to the head.

--the patient should not complain of pain or tenderness during palpation.

brown

--no tenderness

Normal

Normal

Mouth

Breath

Lips

Tongue

Buccal mucosa

Inspection

palpation

--the breath should smell fresh.

--should be pink and moist with no evidence of lesions or inflammation.

--lips should not be flaccid and lesions should not be present.

--tongue is in the midline of the mouth. The dorsum tongue be pink, moist, rough w/o lesions.

--the color of the oral mucosa on the inside of the

--foul smell

--dry

--firm and not soggy

NA

NA

Abormal

Normal

Normal

Diffulty to open the mouth widely

Diffulty to open the mouth widely

Gums

Teeth

check may vary according to race.

-- the gums have pale-red stippled surface.

-- adult has 32 teeth, w/c should be white w/ smooth edges, in proper alignment, and w/o caries.

NA

NA

Diffulty to open the mouth widely

Diffulty to open the mouth widely

Musculoskeletal

Overall appearance

Posture

Gait and mobility

Muscle size and shape

Inspection

--body height and weight should be appropriate for age and gender.

-- in the standing position, the torso ad head are upright.

--walking is initiated in one smooth, rhythmic fashion.

--Muscle shape may be accentuated in certain body areas but should be

--Ht. and wt. is appropriate in

age and gender

--head is upright

--gait is normal

--no twitches

Normal

Normal

Normal

Normal

Joint contour and periarticular tissue

Range of motion

Muscle strength

symmetrical. There is no involuntary movement.

-- joint contour should be somewhat flat in extension, and smooth and rounded in flexion.

--refer to specific sections on joints for the ROM for each joint movement.

--normal muscle strength allows for complete voluntary range of joint motion against both gravity and moderate to full resistance.

--flat in extension

--Normal ROM

--normal muscle strength

Normal

Normal

Normal

Mental status

Physical appearance and behavior

Posture and movement

--the patient should exhibit erect posture, a smooth gait, and symmetrical body

--erect and smooth gait

--slightly clean

Normal

Dress, grooming and personal hygiene

Facial expression

Communication

movements.

-- clean and well groomed, and should wear appropriate clothing for age, weather, and socio economic status.

--facial expression should be appropriate to the content of the conversation and should be symmetrical.

--the patient should be able to produce spontaneous, coherent speech. The speech should be effortless flow with normal inflections.

and well groom fit to her age and gender

--appropriate to age and topic

--Can got attention easily

Normal

Normal

Normal

LA CONSOLACION UNIVERSITY PHILIPPINES

CATMON, CITY OF MALOLOSALLIED MEDICAL SCIENCES

A CASE STUDY

(Nasopharyngeal carcinoma, differentiated Non-keratinizing type 4)

SUBMMITTED TO:

Mrs.Jennifer Manlapig,RN

(Clinical Instructor)

SUBMITTED BY:

Borlongan, Gia Pauline

BSN-4

(August 2011)