I. 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
Transcript
I. 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
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.
II. 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.
III. 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.
EliminationHis elimination is regular, sometimes twice a week and his urination was 2 times
a day. Activity– Exercise
Patient 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.
IV. Review of the system
Anatomy 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:
virus. Alsocalled human 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 exposure(chemicals)
Formation of benign bronchial epethelium tissue.
Transformation of benign tissue into neoplastic tissue
Nasopharyngeal cancer
Squamous cell carcinomaIrritation and obstruction of airwaySputum 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)
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: AbnormalIn 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 scan
Pictures 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: Abnormal
There 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/dl
Hct: 0.29 g/dl NV: 0.40-0.50 g/dl
RBC: 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 normal
SGOT: 20-25u/L NV: 5-40 U/L –within the normal
SGPT: 29u/L NV: 7-56 U/L – within the normal
Total protein: 30-46g/dl NV: 60-85g/dl -abnormal
Albumin: 2.7g/dl NV: 3.4 - 5.4 g/dl –abnormal
AG/ratio: 1.40 NV: 1.7-2.2- within normal
Globulin: 19-30 mg/dl NV: 75 to 300 mg/dL -abnormal
Sodium: 132.0 mEq/L NV: 135 to 145 mEq/L - abnormal
Potassium: 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.
A 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
VI. 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.
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.
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.
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 disease except malabsorption r/t pernicious anemia or GI diseas
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 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
Classification :
Respiratory and intratracheal inhalant, Mucolytic, and an Antidote.
Acetylcysteine splits linkage of mucoproteins. It reduces the viscosity of pulmonary secretions, facilitates removal by coughing, postural drainage, mechanical means. Acetylcysteine protects against acetaminophen overdose-induced liver toxicity.
Acetylcysteine is used in adjunct 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.
Hypersensitivity Stickiness on face
Transient unpleasant odor
Increased bronchial secretions,
Irritated throat
Nauseaand Vomiting
Rhinorrhea
Skin rash
Facial edema
Bronchospasm
Wheezing
Assess pretreatment respirations 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.
.
VII. 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
bleeding, ecchymosis, and vascularity
lesions
Inspection --- the skin is a uniform whitish pink or brown, depending on the patient’s race
-- There are no areas of increased vascularity, ecchymosis or bleeding.
-- no skin lesions should be present except for feckles,
--skin color is brown
--no increase in vascularity
--with lesion on
Normal
Normal
Abormal
moisture
temperature
tenderness
texture
turgor
Palpation
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.
-- 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
lower extremities
-
--Normally dry
--Skin is warm
--nontender
--smooth skin
--With normal skin turgor (<3sec)
Normal
Normal
Normal
Normal
Normal
edema
contour rapidly.
-- edema is not normally present.
Presence of edema on both upper and lower extremities
Abormal
Head Inspection
shape of the head
scalp
face
neck
thyroid gland
--the head should be normocephalic and symmetrical.
--the scalp should be shinny, intact, and without 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.
--symmetrical
--shinny and no lesions or masses
--asymmetrical on right side
--large mass on the both side larger than
right side
Difficult of swallowing
Normal
Normal
Abormal
Abormal
Abormal
lymph nodes
--lymph nodes should not be visible inflamed.
--presence of lympnodes in bpth axilla midsternum
and illeum
Abormal
Head
Scalp
Mandible
Neck
Thyroid gland
Palpation --the normal skull is smooth, nontender, and w/o masses or depressions.
--w/o lesions or masses.
-- 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
--Smooth, non tender, no masses
and depression
--No lesion or masses
-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
Normal
Normal
Abormal
Abormal
Abormal
Lymph nodes
healthy adult patient. and axilla,medsternum
and illeum
Abormal
Ears
Auditory screening
Voice whisper test
External ear Inspection
palpation
--the patient should be able to repeat words whispered from a distance of 2 feet.
--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.
--able to repeat word, but th
pt.hearing is slightly unclear
--pinkish to brown
--no tenderness
Abormal
Normal
Normal
Mouth
Breath
Lips 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.
--foul smell
--dry
--firm and not soggy
Abormal
Normal
Normal
Diffulty to
Tongue
Buccal mucosa
Gums
Teeth
--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 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
NA
NA
open the mouth widely
Diffulty to open the mouth
widely
Diffulty to open the mouth
widely
Diffulty to open the mouth
widely
Musculoskeletal
Overall appearance
Posture
Gait and mobility
Muscle size and
--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
--Ht. and wt. is appropriate in age
and gender
--head is upright
--gait is normal
Normal
Normal
Normal
shape
Joint contour and periarticular tissue
Range of motion
Muscle strength
Inspection
accentuated in certain body areas but should be 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.
--no twitches
--flat in extension
--Normal ROM
--normal muscle strength
Normal
Normal
Normal
Normal
Mental status
Physical appearance and behavior
Posture and movement
Dress, grooming and personal hygiene
--the patient should exhibit erect posture, a smooth gait, and symmetrical body movements.
-- clean and well groomed, and should wear appropriate clothing for age,
--erect and smooth gait
--slightly clean and well groom fit to her
age and gender
Normal
Normal
Facial expression
Communication
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.
--appropriate to age and topic
--Can got attention easily
Normal
Normal
LA CONSOLACION UNIVERSITY PHILIPPINES
CATMON, CITY OF MALOLOSALLIED MEDICAL SCIENCES
A CASE STUDY
(Nasopharyngeal carcinoma, differentiated Non-keratinizing type 4)
