Case Study Final

1

INTRODUCTION

“A wise man should consider that health is the greatest of human blessings, and learn how by his own thought to derive benefit from his illnesses.”

- Hippocrates

Every individual aspires to be as healthy as they currently can, but as it turns out, life isn’t that simple. It’s not merely hand-me-downs but rather a struggle that one continually strives for to provide at any given time a most pleasant experience there is. Through life, individuals also have unfavorable experiences regarding health. To just sit back and think of it as an unfortunate circumstance or a faulty decision made should not be the primary reason that the human population remain satisfied with what they have but rather prioritize on how to manage such condition towards the betterment of one’s health.

Ovarian cancer (OC) is the eighth most commonly diagnosed cancer among women in the world, accounting for nearly 4 % of all female cancers. OC also represents the third leading gynecologic cancer, following cancer of the cervix and uterine corpus, and causes more deaths per year than any other cancer of the female reproductive system. On a worldwide basis, an estimated 225,000 new cases are diagnosed and 140,000 women die of OC annually. In 2011, approximately 22,000 new cases of OC were diagnosed and 15,500 OC-related deaths occurred in the United States. A woman’s risk of developing OC in her lifetime is 1 in 71, and her chance of dying of the disease is 1 in 95. Mortality is high because women typically present with late stage disease when the overall 5-year relative survival rate is 44 %. Thus, the public health burden is significant (Farghaly, 2014).

Cancer does not choose. It strikes at any moment, at any time, at whichever place, and to whoever it desires to. It has been a perennial scare, a very dreaded fright to mankind. This case study shall be tackling the known female reproductive cancer, the ovarian cancer. The American Cancer Society for ovarian cancer in the United States for 2015estimates that about 21,290 women will receive a new diagnosis of ovarian cancer. Further, the esteemed organization predicts that about 14,180 women will die from ovarian cancer. Ovarian cancer ranks fifth in cancer deaths among women, accounting for more deaths than any other cancer of the female reproductive system. A woman's chance of dying from ovarian cancer is about 1 in 100. (These statistics don’t count low malignant potential ovarian tumors.) Nonetheless, it is noteworthy that the rate at which women are diagnosed with ovarian cancer has been slowly falling over the past 20 years. (Allan, 2011)

http://www.quoteopia.com/famous.php?quotesby=hippocrates

2

GENERAL PROFILE

Personal profile

Name: Patient OvaSex: FemaleAge: 25 years oldOccupation: Housekeeping Permanent address: Irisan, Baguio City, BenguetMarital Status: MarriedBirth Date: January 16, 1989 Nationality: Filipino Religion: Roman Catholic Admission: January 9, 2015 Date of Discharge: January 16, 2015 Admitting physician: Dr. Hermie, MD

Presenting Complaints:

Patient Ova was admitted at the Baguio General Hospital and Medical Center (BGHMC) at 6:50 in the evening of January 9, 2015 with complaints of abdominal pain and enlargement.

One week prior to admission, she was suffering from unbearable abdominal pain. Accordingly, she suffers from sharp right lumbar pain that is localized only to the right side of her abdomen. She describes her pain to be 10 out of 10 in the Visual Analog Scale. She mentioned that the pain is usually aggravated by a change in position – usually when she turns to the side when originally on supine. Furthermore, last December, she observed that the pain intensifies when her abdomen gets exposed to cold. The pain is intermittent, she claimed. She experiences moderate to severe pain with an interval of about 10-30 minutes daily up to the date of consultation. At most parts of the day, she tolerates mild-moderate pain and does not allow it to interfere with her ADLs.

Aside from the complaint of rapid abdominal enlargement that commenced 4 months ago, she further claimed to have experienced amenorrhea, weight loss, anorexia, and nausea and vomiting. She consulted a physician early in January and was advised to undergo surgery. As stated, she was admitted at the Baguio General Hospital and Medical Center for Total Abdominal Hysterectomy and Salphingooophorectomy.

Principal Diagnosis:

G2P2 (2002) Ovarian New Growth, Right, Probably Immature Cystic teratoma malignancy

History of Present Illness:

Patient Ova was apparently normal until late September 2014. Accordingly, she occasionally experienced sharp right lower abdominal pain that particular month. Despite her condition, she never sought consultation believing that the pain would go away as she had been dosing herself with Mefenamic Acid. In addition, she claimed that she has not noted any changes in bladder and bowel movements. Her condition persisted and with it, she saw her abdomen enlarge until it eventually

3

appeared like a visible elbow-like firm mass. After consultation on January 9, 2015, at about a quarter before 7 pm, admission was decided.

Huether and McCance (2011) cited that ovarian cancer is a silent killer because at the time of consultation, the cancer cells have already metastasized considering that symptoms come and go for months, not causing alarm to the cancer-inflicted individuals. Martin (2006) found that 70% of women with ovarian cancer had symptoms for 3 months or longer before diagnosis. These findings are consistent with Patient Ova’s case, whereby it took four months before she was medically diagnosed with the cancer.

Past Medical History

The patient claimed that she doesn’t have allergies and other illnesses. Surgical history reveals that her two (2) children were both delivered via Low Segment Caesarean Section, as stated by the patient herself. At present, her GTPAL Score is G2T2P0A0L2.Her latest delivery was last May 2014.

The patient also mentioned that she and her partner never employed any of the known birth control methods, let alone birth control pills. Huether and McCance (2011) cited that protection given by birth control pills may be more than just stopping egg-related release and allowing ovaries’ outer lining to undergo less wear and tear, as how it happens during conception. Progestin in these pills may enhance apoptosis – allowing the body to dispose of mutated cells.

According to the American Cancer Society (2014), women who have been pregnant and carried it to term before age 26 have a lower risk of ovarian cancer than women who have not. The risk goes down with each full-term pregnancy. Ova’s case can be considered truly rare, considering that she has already bore 2 children at 24. As of writing, she is 25 years old.

Social and Environmental History

A study asserted that green leafy vegetables were strongly associated with decreased risk for ovarian cancer. No consistent association was found with meats, breads, cereals, and starches (Larsson, Holmberg, and Wolk, 2004). Meanwhile, Larsson, Bergkvist, and Wolk (2004), found that no relationship was found between alcohol use and ovarian cancer risk. However, another study showed that an intake of 10g/day of alcohol decreased the risk of ovarian cancer by 50% (Larsson, Holmberg, and Wolk, 2004). By and large, the studies indicate that the risk only increases when there is a daily alcohol intake of more than 10g/day.

Conversely, through interviews with the patient and her family members, Patient Ova was found to have had a good lifestyle. She never smoked nor consumed noteworthy amounts of alcohol. Furthermore, it was known that she has been maintaining a healthy and balanced diet. In support, her mother-in-law said, “As to her lifestyle, walaakongmasabi. Kumakainsiyangprutas, gulay, at kontingkarne. I never saw her smoke. Para ngangsabuongpagkakakilalakosakanya, minsankolangsiyanakitangnakainom – nu’ng birthday nganakniya.” (As for her lifestyle, I could notcomment anything. She eats fruits, vegetables, and minimal amounts of meat. In all those times that I have known her, I think I have only seen her drink alcohol once. And that was only during her child’s birthday.) Hence, her maintenance of a healthy lifestyle would justify crossing out of the risk factors mentioned above, considering that she still got the disease despite practice of it.

4

Her family members also declared that she wasn’t exposed to heat and industrial carcinogens (talc and asbestos) that may become factors in the development of cancer as she spends her time with her children outside their house. It was noteworthy that she was an Irisan resident; the student nurse assigned to her ascertained the exact location of their abode. Her sister ensured that they were not affected by the dumpsite, saying, “Malayonamaniyongpinagbabasurahansa place namin”. (Our place is far from the dump site.)

It has been proven that women exposed to asbestos in their reproductive years have a two-fold increased risk for ovarian and other cancers of the pelvis in a dose dependent manner (WHO, 2008).Also, several studies found a positive association between talc use and increased risk of ovarian cancer (Harlow, et al, 1999).

When asked what her stressors are at the moment, she did not respond and simply smiled. In place, her mother-in-law disclosed that his son, the client’s husband, seem to be indifferent of their marriage. He does not stand as the family’s pillar, nor does he recognize that he is actually a married man. As a result, all burdens are carried by the client. Despite the irresponsibleness of her husband, she never gave up, with her mother-in-law and other relatives helping her time and again.

Stewart, Duff, Wong, Melanconand Cheung (2001) have found that among the ovarian cancer survivors they have studied, 63.5% of them attributed their cancer to stress. Meanwhile, a study conducted bySood, Thaker, Han,and Kamat (2006) indicated that cancer cells make receptors for stress hormones on their surface and that when these receptors are activated they set in motion a chain of events that leads to formation of new blood vessels that feed tumors, a process called angiogenesis. New blood vessel formation is known to allow tumors to grow and spread more rapidly.In their experiment, they developed a mouse model of ovarian cancer to study the link. In their experiments, the researchers confined the mice in a small space for zero, two or six hours during the day.The confinement caused the mice to produce the same stress hormones as humans produce when they are under stress. These beta adrenergic hormones are sometimes called the "fight-or-flight" hormones because they are released when people are fearful or threatened, and are also responsible for causing the heart to beat harder and faster.

Family History

The patient and her sister admitted that there are hereditary or familial origins of the disease in their family. They stated that two of the patient’s cousins were diagnosed with colon cancer. Further, an aunt of hers, particularly her mother’s sister,and another relative were diagnosed with breast cancer. Meanwhile, she revealed that her father has a history of hypertension.

Ovarian cancer can run in families. Studies have shown that ovarian cancer risk increases ifa relative has or had ovarian cancer. One’s risk increases as the degree of relation with the cancer-inflicted relative is closer. The risk also gets higher when morerelatives have ovarian cancer (American Cancer Society, 2014). A family history of some other types of cancer such as colorectal and breast cancer was also linked to an increased risk of ovarian cancer. This is due to the fact that these cancers can be causedby an inherited mutation (change) in certain genes that cause a family cancer syndrome that increases the risk of ovarian cancer called the Lynch Syndrome (American Cancer Society, 2014).

Anchored with the above notations, it may be pondered that her acquisition of ovarian cancer is primarily family-based when the risk factors are individually weighed.

5

PHYSICAL EXAMINATION

General Survey

Patient Ovais a petite young woman of 25. She stands at about 5 feet tall and after surgery, she weighed in at 48 kilograms. She was fully aware of her condition. She appeared weak, and on occasions, she looked a bit irritable. She exhibited thought association and spoke in a moderate volume and in an understandable manner.

An assessment revealing a conscious and coherent status indicates that the client is in good general health and is aware of her name, her location,and the present date and time when inquired. At the time of case-taking, her vital signs were within the normal range.

HEENT

Her head was normocephalic and symmetrical. Upon palpation, it was noted that the skull was smooth, non-tender, and without masses or depressions. The temporal artery was readily compressible. Her scalp was shiny, intact, and without lesions.

Her face was symmetrical. Both palpebral fissures were equal and the nasolabial fold was present bilaterally. She has an oval-shaped face; no edemanor disproportionate structures seen. The temporomandibular joint articulated smoothly and there was no clicking nor crepitus noted upon assessment.

The patient has a visual acuity of 20/20. Her eyelids appeared symmetrical with no drooping. Lid margins were smooth with the lashes evenly distributed and sweeping upwards from the upper lids and downwards from the lower lids. Eyebrows were present bilaterally and are symmetrical. No lesions nor scaling were noted. Both eyes were noted to move smoothly and symmetrically in each of the sic field of gaze.

The bulbar conjunctiva was transparent with small blood vessels visible in them. Each appeared white except for a few small blood vessels. No foreign bodies or exudates were seen. The palpebral conjunctiva appeared pink and moist. Her sclerae were white. Upon inspection, it was noted that the corneal surfaces were moist and shiny, with no discharge, cloudiness, opacities or irregularities.

The pupils were dark brown, round, and of equal diameter. They were reactive to light and accommodation.

Her ears match the flesh color of the rest of her skin and were positioned centrally and in proportion to the head. No complaint of pain or tenderness was noted during palpation. The ear canals were negative of signs of inflammation.

Each nostril was patent. The nasal mucosa was pink without swelling or polyps. The septum is at the midline and without perforation, lesions, or bleeding. No discomfort was elicited when the sinuses were palpated.

6

Her lips and membranes were pink and moist with no evidence of lesions or inflammation. The tongue is in the midline of the mouth and appeared symmetrical. The dorsum of the tongue appeared pink, moist and rough. It was able to move freely. The buccal mucosa was moist, smooth, and free of signs of inflammation. Similarly, the gums were pink and moist. The gum margins were well defined with no pockets existing between the gums and the teeth.

She had a complete set of permanent teeth; caries were noted at her premolars. The hard and soft palates were concave and pink.

The muscles of the neck were symmetrical with the head in a central position. The patient was able to move the head through a full range of motion without complaint of discomfort or noticeable limitation. The muscles were also symmetrical with no palpable masses or spasms. The thyroid was not enlarged. There were no abnormal masses palpated and tenderness was not noted. Lymph nodes were not palpable.

Respiratory system

The patient has clear breath sounds. She exhibits full symmetric chest expansion when asked to take a deep breath. She does not use accessory muscles when breathing. Her respirations were regular and even in rhythm. She breathes comfortably in supine, prone, or upright position, except on occasions when pain aggravates. Normal fremitus was elicited upon palpation.

Cardiovascular system

Patient Ova claimed to have never experienced chest pain. She did, however, state that she has been experiencing dyspnea. Upon auscultation, regular heartbeatswere heard; the heart was negative of murmurs. Her pulses were of normal volume – moderate amount of pressure of the fingers were needed to obliterate the pulses.

Gastrointestinal system

Her abdomen was quite flabby and smooth with consistent softness. It was bilaterally symmetrical. Her abdominal skin was also uniform in color and pigmentation. A dark brown surgical scar of about 3 inches in length was noted at the midline. During inspection, no striae were present. Bowel sounds were heard as intermittent gurgling sounds throughout the abdominal quadrants.

Thepatient has right lower abdominopelvic pain rated as moderate to severe. Nausea and vomiting were also evident due to the abdominal distention,increasing the pressure of the pelvic area. During the interview, she claimed that a week prior to consultation, she was not able to pass stool for 4consecutive days.

Genito-urinary system

Before the patient underwent surgery, frequency in urination was claimed. This may be explained by the presence of the tumor pressing the bladder.

Musculoskeletal system

7

No deformities, tenderness, or swelling was palpated on the patient’s bones and joints. She was able to move joints smoothly when she was asked to perform range of motion exercises.

Integumentary system

She is fair in complexion and without body odors. After being pinched, her skin goes back to its normal color. Her hair is long and black. Her nails are clean and neatly cut. After performing Blanch Test, her nailbeds were noted to have returned to their original color in less than 3 seconds. Her nails are concave, light pink, and smooth.

8

DIAGNOSTIC AND LABORATORY PROCEDURES

Table 1. Abdominal Ultrasound

Date and Time

Procedure

Description and Purpose Result of the Test

January 6, 2015

Abdominal Ultrasound

Ultrasound produces sound waves that are beamed into the body causing return echoes that are recorded to "visualize" structures beneath the skin. Harmless, high-frequency sound waves are emitted from a transducer and penetrate the structure to be studied. The sound waves are bounced back to the sensor with the transducer and, by electronic conversion, are arranged into a pictorial image of the desired organ. A realistic paper is reproduced on print or x-ray film (Pagana and Pagana, 1994).Obstetrics:Ultrasound in obstetrics is used to diagnose growths or tumors of the ovary, uterus, and Fallopian tubes. It is used in making differential diagnoses of various uterine and ovarian enlargements (Pagana and Pagana, 1994).Abdominal structures:Aside from its use in obstetrics, ultrasound can evaluate most of the solid structures in the abdominal cavity. This includes the liver, gallbladder, pancreas, kidneys, bladder, prostate, testicles, uterus, and ovaries (Pagana and Pagana, 1994).

- Large intra-abdominal mass predominantly solid, to consider an ovarian tumor.

- Moderate ascites.

- Normal liver, gallbladder, CBD, pancreas, kidneys and urinary bladder.

Ultrasound is often the first test done if a problem with the ovaries is suspected. It can be useful finding an ovarian tumor and seeing if it is a solid mass (tumor) or a fluid-filled cyst. It can also be used to get a better look at the ovary to see how big it is and how it looks inside (the internal appearance or complexity). These factors help the physician decide which masses or cysts are more worrisome (American Cancer Society, 2014).

As gleaned, the impression was a “large intra-abdominal mass predominantly solid, to consider an ovarian tumor.”Pagana and Pagana (1994) have stated that ultrasound findings must be correlated with the clinical findings because malignancy, ovarian abscess, and endometriosis may appear similar (Pagana and Pagana, 1994). The ultrasonography results could not stand alone when diagnosing cancer.

Accordingly, the predominant solid lobulated mass found in the right ovary was measured to be 22.0 x 19.0 cm (8.61 x 7.48 inches). It pushes bowel segments superiorly and post-laterally. This may be correlated with the pain experienced by the patient. According to the Canadian Cancer Society (2014),

9

ovarian cancermay not cause any signs or symptoms in theearly stages because a tumor has room togrow and expand in the abdomen. Symptoms appear once the tumor grows into surroundingtissues and organs (metastasis). Metastasis was not noted in the ultrasound; nonetheless, the size of the tumor may have affected the surrounding tissues, increasing the pressure intra-abdominally. As a result, pain, bloating, feeling of fullness, and frequency in urination was manifested by the patient.

Table 2. Complete Blood Count

Date and Time

Procedure


January 8, 2015

Complete Blood Count

A complete blood count (CBC) is a calculation of the cellular makeup 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. It may be a part of a routine check-up or screening, or as a follow-up test to monitor certain treatments. It can also be done as a part of an evaluation based on a patient's symptoms. A CBC measures the concentration of white blood cells, red blood cells, and platelets in the blood and aids in diagnosing conditions and disease such as malignancy, anemia, or blood clotting problems.

WBC: Leukocytes

Initial: 5.39x10^9/LRepeat: 11.66x10^9/L

Reference Range: 5.0-10.0x10^9/L

WBC: NeutrophilsInitial: 0.803Repeat: 0.75

Reference Range: 0.50-0.70

In diagnosing ovarian cancer, blood is taken and studied to seeif the different types of blood cells are normal in number and appearance. The results show how well the organs are working and may suggest whether one has cancer and if it has spread (Canadian Cancer Society, 2013).

During the initial CBC Count, the WBC result was within normal range. However,when repeat CBC was ordered, the WBC was observed to have increased. Pagana and Pagana (1994) stated that an increased WBC count (leukocytosis) usually indicates infection. It shall be noted that trauma and stress, either emotional or physical, can increase the WBC count (Pagana and Pagana, 1994). Thus, in the study’s case focus, the increased WBC count may be associated with infection and physical and emotional stress.

The neutrophil count is above the normal range – indicative of impaired immune system suggesting in particular, acute bacterial infection. However, effectivity of management may be considered as the repeat CBC count resulted with a rather lower neutrophil count, falling to 75. Nonetheless, the count was still above the normal. According to Pagana and Pagana (1994), the neutrophils are the most important leukocyte in the body’s defense against microbial invasion. Similarly, elevation indicates physical or emotional stress, acute suppurative infection, and trauma. Considering the malignancy, it may be expected that this important leukocyte is increased.

10

Table 3: Chest X-ray

Date and Time

Procedure


September 12, 20149:20 am

ChestX-ray

This procedure uses penetrating radiation having a shorter wavelength than light to produce images of the heart, lungs, blood vessels, airways, and the bones of the chest and spine. As radiation penetrates the body, it is absorbed in varying amounts by different body tissues depending on the tissue's composition of air, water, blood, bone, or muscle. It is most commonly used to detect abnormalities in the lungs, but can also detect abnormalities in the heart, aorta, and the bones of the thoracic area.Chest X-rays can also reveal fluid in or around lungs or air surrounding a lung. It also performed to evaluate for flail chest (loss of stability of the rib cage following fracture of the breast bone or ribs). A patient to undergo the procedure is asked to stand in front of the x-ray machine following a removal of all metal accessories worn. The technician will require the patient to stand against the machine, and then sideways. Also, he will be told to hold his breath while the two images are being taken. (Mayo Clinic, 2014)

-No active lung infiltrations.

-Heart is not enlarged.

-Pulmonary vascular markings are within normal range.

-Both costophrenics sulci and hemi diaphragm are intact.

-Visualized osseous structures are unremarkable.

In the diagnosis of ovarian cancer, this procedure is being done to determine whether ovarian cancer has spread(metastasized) to the lungs. This spread may cause one or more tumors in the lungs andmost often causes fluid to collect around the lungs. This phenomenon called a pleural effusioncan be seen with chest x-rays as well as other types of scans (American Cancer Society, 2008).

As gleaned, there were normal chest findings in general. The results support the absence of any respiratory problem during physical and medical examination.

Table 4: Electrocardiogram

Date and Time

Procedure


January 12, 2015

The electrocardiogram (ECG or EKG) is a noninvasive test used to reflect underlying heart conditions by measuring the

(RSR) Reverse sloping ST

11

ECGelectrical activity of the heart. By positioning leads (electrical sensing devices) on the body in standardized locations, information about many heart conditions can be learned by looking for characteristic patterns on the EKG. (Medicine.net, 2015)

segment in V3 to consider ischemia.

Table 5: Tumor Marker Testing (CA-125)

Date and Time

Procedure


January 9, 2015

10:20 am

CA 125 is a protein that is a so-called tumor marker or biomarker, which is a substance that is found in greater concentration in tumor cells than in other cells of the body. In particular, CA 125 is present in greater concentration in ovarian cancer cells than in other cells. It was first identified in the early 1980s, and the function of the CA 125 protein is not currently understood. CA stands for cancer antigen.The normal values for CA 125 may vary slightly among individual laboratories. In most laboratories, the normal value is less than 35 U/mL.CA 125 is used most often to monitor patients with a known cancer (malignancy) or as one of several tests in the workup of a patient suspected of having a tumor.The most common use of the test is the monitoring of people with a known cancer that elevates CA 125 level, such as cancer of the ovary.A decreasing level generally indicates that therapy, including chemotherapy, has been effective, while an increasing level indicates tumor recurrence. (Medicine.net, 2015)

Result: 328.50 U/mL

Reference Range: 0 – 32.2 U/mL

Canadian Cancer Society elaborates that after blood tests, the blood may also be tested for body chemicals called tumour markers. For ovarian cancer, the blood may be tested for several tumour markers, including CA-125. CA-125 is a substance found in ovarian cancer cells and in some normal tissues. CA-125 can also help tell whether the cancer has spread or not.As a tool, serial changes in CA 125 levels, if elevated, canbe fairly representative of disease status and frequently very helpful in theassessment of women with ovarian cancer (Foundations for Women’s Cancer, 2011).

Table 6: Urinalysis

Date and Description and Purpose Result of the Test

12

Time ProcedureJanuary 9,

2015

10:24 am

Urinalysis

A urinalysis is simply an analysis of the urine. It is a very common test that can be performed in many healthcare settings including doctors' offices, urgent care facilities, laboratories, and hospitals.Urine can be evaluated by its physical appearance (color, cloudiness, odor, clarity), or macroscopic analysis. It can be also analyzed based on its chemical and molecular properties or microscopic assessment. (Nabili, 2014)

Color: dark-yellowAppearance: turbidSpecific gravity: 1.020pH: 6.0Bilirubin: positive onePus cells: 1-2Bacteria: occasionalEpithelial cells: manyAmorphous materials:moderate

In the case, the CA 125 result is highly above the normal range. Since the CA 125 test reflects the amount of protein (often called antigen) released into the blood stream from specific organs, conditions that “perturb the silence” change the test result. Ovarian cancer not only increases the number of cells that make CA 125, but also perturbs or inflames the abdominal lining, which contains “normal” cells that make and release CA 125. So, it’s not surprising that CA 125 is elevated in ovarian cancer and in some other cancers in the abdomen (Foundations for Women’s Cancer, 2011).

In the urinalysis result, only the pH level and specific gravity were found to be normal.

First, the urine color was dark-yellow. The color indicates the concentration of the urine and varies with the specific gravity (Pagana and Pagana, 1994). The color is nearer to the darker spectrum, indicating that the urine is more concentrated than normal.

It was turbid in appearance. The normal urine specimen should be clear. Turbidity may suggest presence of bacteria and pus (Pagana and Pagana, 1994).

The pH level was normal.

Demonstration of bacteria, pus cells, and epithelial cells on microscopic examination, as seen in the result, indicates urinary tract infection.

Table 7: Biopsy

Date and Time

Procedure


January 12, 2015

10:10 am

Biopsy

The only way to determine for certain if a growth is cancer is to remove a sample of the growth from the suspicious area and examine it under a microscope. This procedure is called a biopsy. For ovarian cancer, the biopsy is most commonly done by removing the tumor. The sample tissue obtained is sent to the laboratory. There it is examined under the microscope by a pathologist, a doctor who specializes in diagnosing and classifying diseases by examining cells under

“Malignancy” of the sample was confirmed via SMS.

13

a microscope and using other lab tests (American Cancer Society, 2008).

The patient underwent TAHBSO on the January 13, 2015 and concurrently, collection of biopsy sample was done. The group’s rotation ended on the 17th, and she was discharged a day prior. Results of the biopsy were to be released for about 3-4 weeks after; hence, the only way the group was able to confirm the results was through a call despite the informality.

CASE STUDY

Ovarian cancer still proves to be a killer. As of the moment, thousands are suffering from it unknowingly. As discussed by Behtash, Ghayouri, and Fakhrejahani (2008), most women with ovarian cancer are diagnosed whenthe disease is advanced and difficult to cure.

Medical Diagnosis

Ovarian New Growth, Right, Probably Immature Cystic teratoma malignancy

The initial diagnosis considered was a teratoma. The American Cancer Society described teratomasas germ cell tumors with areas that, when seen under the microscope, looklike each of the 3 layers of a developing embryo: the endoderm (innermost layer),mesoderm (middle layer), and ectoderm (outer layer). This germ cell tumor has a benignform called mature teratoma and a cancerous form called immature teratoma.(American Cancer Society, 2015)

In this study, the teratoma seen was of the immature type, indicating that the growth was malignant. They occur in girls and young women, as comparable to the case focus who is a young adult. These are rare cancers that contain cells that look like those from embryonic or fetal tissues such as connective tissue, respiratory passages, and brain. Also, these tumors can contain different kinds of tissues including, bone, hair, and teeth. (American Cancer Society, 2015)

Pathophysiology

Cancerbegins in cells, the building blocks that make up tissues. Tissues make up the organs of the body. Normally, cells grow and divide to form new cells as the body needs them. When cells grow old, they die, and new cells take their place. Sometimes, this orderly process goes wrong. The instructions in somecells get mixed up, causing them to behaveabnormally. These cells grow and divideuncontrollably. New cells form when the body does not need them, and old cells do not die when they should. These extra cells can form a mass of tissue called a growth or tumor (Smeltzer et.al, 2008).

Ovarian cancer begins in the ovaries. Ovaries are reproductive glands found only infemales (women). The ovaries produce eggs (ova) for reproduction. The eggs travelthrough the fallopian tubes into the uterus where the fertilized egg implants and developsinto a fetus. The ovaries are also the main

http://www.medicinenet.com/script/main/art.asp?articlekey=13931

14

source of the female hormones estrogen andprogesterone. One ovary is on each side of the uterus in the pelvis. (American Cancer Society, 2015)

During ovulation (the process during which the egg ripens and is released from the ovary), the ovary produces a hormone to make the follicles (sacs containing immature eggs and fluid) grow and the eggs within it mature. Once the egg is ready, the follicle ruptures and the egg is released. Once the egg is released, the follicle changes into a smaller sac called the corpus luteum. Ovarian cysts occur as a result of the follicle not rupturing, the follicle not changing into its smaller size, or doing the rupturing itself. (American Cancer Society, 2015)

Some recent studies have indicated that the majority of women with ovarian cancer actually do experience symptoms before their diagnosis. However, since symptoms may be subtle, and vary from person to person, they may not be associated with the symptoms of ovarian cancer, according to the American Cancer Society (2014).

The symptoms of ovarian cancer are vague and the causes may be related to several factors. As Bohnenkamp (2007) has explained, one or more risk factors may increase the likelihood of developing ovarian cancer, but their presence does not guarantee the cancer will occur. Martin (2006) claimed that the most significant risk is a positive family history of the disease; it is present in about 10% of women with the disease. Ignatavicius (2006) noted that other risk factors include being over the age of 40, family history, diabetes mellitus, null parity, being under 30 years of age at first pregnancy, breast cancer, colorectal cancer, and infertility. Martin (2006) found that 70% of women with ovarian cancer had symptoms for 3 months or longer before diagnosis. Similarly, Behtash et al. (2008) a highproportion of women with ovarian cancer noted somesymptoms in the months before diagnosis which is also consistentwith previousreports of case series.

Sharp right lower abdominopelvic painwas experienced by the patient. A normal ovary is 2.5-5 cm long, 1.5-3 cm wide, and 0.6-1.5 cm thick. The tumor was measured to be 22.0 cm x 19.0 cm in the ultrasonography, about ten times larger than the normal ovary. As a result, the tumor found in the ovary may be the assumed cause ofpain as it stretches the structure, twisting on its pedicle. Also, the pain may be associated with the increase in uterine muscle contractility which increases lactic acid formation, irritating the nerve endings, thereby causing pain. Moreover, when the tumor causes pain, it usually cause pain off on one side or the other, and the pain can radiate slightly around the flank. This has also occasionally been manifested by the present study’s case focus. A study conducted by (Behtash et al., 2008) shows that the most common symptom among the cases was unusual abdominal or lower backpain mentioned by 52% of cases and 11% of controls(OR = 8.7, 95% CI 4.1, 18.3).

Amenorrhea was also noted. In ovarian cancer, the ovary doesn't make all of the hormones it needs for an egg to fully mature. The follicles may start to grow and build up fluid but ovulation does not occur. Instead, some follicles may remain as cysts. For these reasons, ovulation does not occur and the hormone progesterone is not made. Without progesterone, a woman's menstrual cycle is irregular or absent. Plus, the ovaries make male hormones, which also prevent ovulation.

Meanwhile, the abdominopelvic pressure or fullnessfelt by the patient may be associated with the direct pressure from thetumor.The findings of Behtash et al. (2008) concerning unusual bloating, fullness, and pressure in the abdomenor pelvis among 37%of their study’s cases and 3% of their controls concurs with the present study’s findings.

15

Further, the patient claimed to have experienced nausea and vomiting. These gastric manifestations may be a sign of torsion or twisting of the ovary on its blood supply, or rupture of the tumor with internal bleeding. Other contributing factors would be the resulting abdominal distention from the increase in growth of the tumor,thereby increasing pressure of the pelvic area. Similarly, Behtash et al. (2008) reported that gastro-intestinal problems, including nausea, vomiting, gastroenteritis, food intolerance, diarrhea, constipation,and intestinal gas were common symptoms, mentioned by 36% of cases and 12% of controls.

Frequency in urination. This may be attributed to the direct pressure from the tumor pressing the urinary bladder, making the client urinate more than 10 times/day. A normal individual urinates not more than 7 times in 24-hour period.Behtash et al. (2008) discovered that this symptom is experienced in less numbers among their respondents, amounting to about 21% of the population.

Anorexia and weight loss.Vasilev (2012) stated that cancer cells produce biochemicals, called cachexins, which circulate in an ovarian cancer patient’s blood and cause fatigue, loss of appetite(anorexia), and general wasting of muscle. Technically, up to half of all cancer patients die of malnutrition, not catastrophic complications from the cancer. This is an even bigger problem in ovarian cancer because the intestine itself is attacked by tumors which mechanically interfere with nutritional support. Avoiding protein-calorie malnutrition is critical to immune function, which is also compromised in cancer patients.

Meanwhile, due to anorexia and diminished food intake, along with suboptimal exercise, as claimed by the client, the muscle and other protein stores have been wasting away, along with her immune system. Apparently, she lost about 10 kilograms as her condition worsened on the month prior to consultation.

16

Figure 1. General Pathophysiology

Formation of germ cells

Malignant transformation of the germ cells

Enlargement of malignant tumor of the right ovary

Uterine contractility

Intra-abdominal pressure

Abdominal Pain

Feeling of Fullness

Nausea and Vomiting

Hormonal Imbalances

Amenorrhea Anorexia Weight Loss Frequency in Urination

Malfunction in gonadogenesis

Ovarian Cancer

17

TREATMENT AND MEDICATIONS

Table 8: Ferrous sulfate

Drug Description and Purpose Nursing Interventions orConsiderations

January 10, 2015

6:00 am

Ferrous sulfate 1 capsule OD

A drug which provides elemental iron, an essential component in the formation of hemoglobin. Between-meal doses are preferable when taking (it can be given with some foods although absorption may be decreased.)(Hodgson, 2013)

a. Monitor hemoglobin level, hematocrit and reticulocyte count during therapy.

b. Give liquid preparations through plastic straw to avoid discoloration of tooth enamel.

c. Instruct patient to take tablet with juice (preferably orange juice) but not with milk, antacids, and caffeine as they interfere with the absorption.

Advise patient to report constipation and change in stool color or consistency.(Hodgson, 2013)

It was indicated in her complete blood count result that her haemoglobin and hematocrit levels were near borderline low. Ferrous sulfate helps in normalizing the levels as it replaces iron stores needed for red blood cell development, energy, and oxygen transport utilization.

Table 9: Bisacodyl


January 12, 2015

12:35 pm

Bisacodyl5 mg/tab, 4 tabs after lunch and another 4 tabs after dinner.

*Another order on the same day was 10 mg/supp., 2 supp. per rectum at 2 am.

A stimulant laxative that works by increasing the amount of fluid/salts in the intestines. This effect usually results in a bowel movement within 15 to 60 minutes.

a. Watch out for adverse effects such as signs of dehydration.

b. Periodically evaluate the patient’s need for continued use of drug; bisacodyl usually produces 1 or 2 soft formed stools daily.

c. Monitor patients receiving concomitant anticoagulants.

d. Add high-fiber foods slowly to regular diet to avoid gas and diarrhea. Adequate fluid intake includes at least 6–8 glasses a day.

Bisacodyl (Dulcolax) acts directly on the bowels, stimulating the bowel muscles to cause a bowel movement. It is used for short-term treatment of constipation, either chronic or of recent onset, whenever a stimulant laxative is required. It is also used for preoperative procedure. Since the patient

18

was scheduled for operation on January 13, 2015, the drug was prescribed to clean/remove wastes in her intestine inpreparation for surgery, thereby reducing the possibility of the occurrence of postoperative infections.

Table 10: Cefoxitin sodium


January 13, 2015

6:00 am

Cefoxitin sodium (Mefoxin) 2g intravenously after negative sensitivity test 1 hour prior to OR

An antibiotic classified under second generation cephalosphorin. This serves as a bactericidal thus inhibiting the synthesis of bacterial cell wall, causing cell death.(Hodgson, 2013)

a. Identify onset, severity, location, and other association factors

b. Ask patient if he is allergic to penicillin or cephalosporins before administering.

c. Advise patient to report any adverse reactions and signs and symptoms of superinfection.

Instruct patient to report severe diarrhea, difficulty of breathing, unusual tiredness or fatigue, and pain at injection site.(Hodgson, 2013)

Cefoxitin (Mefoxin) is indicated for infections such as intra-abdominal infections, gynecologic infections, septicemia,and also as a perioperative prophylaxis. Infection is common after surgery, thus this antibiotic was ordered to combat possibilities of acquiring such.

Table 11: Ketorolac


January 13, 2015

11:40 am

Ketorolac (Toradol) 30 mg intravenously every six hours for four doses

A nonsteroidal anti-inflammatory agent, nonopioidanalagesic that inhibits prostaglandin synthesis, producing peripherally mediated analgesia. It also has antipyretic and anti-inflammatory properties.(Hodgson, 2013)

a. Patients who have asthma, aspirin-induced allergy, and nasal polyps are at increased risk for developing hypersensitivity reactions. Assess for rhinitis, asthma, and urticaria.

b. Assess pain (note type, location, and intensity) prior to and 1-2 hr following administration

c. Caution patient to avoid concurrent use of alcohol, aspirin, NSAIDs, acetaminophen, or other OTC medications without consulting health care professional.

d. Advise patient to consult if rash, itching, visual disturbances, tinnitus, weight gain, persistent headache, or influenza-like syndromes (chills,fever,muscles aches, pain) occur.

Effectiveness of therapy can be demonstrated by decrease in severity of pain.(Hodgson, 2013)

19

Table 12: Tramadol


January 13, 2015

11:40 am

Tramadol (Ultram) 30 mg intravenously every six hours for two doses

An analgesic that binds to opioid receptors and inhibits the reuptake of norepinephrine and serotonin; does not cause histamine release or affect heart rate.(Hodgson, 2013)

a. Reassess patient’s pain level at least 30 minutes after administration.

b. Assess bowel function and need for stool softeners or laxatives.

c. Monitor I and O: check for decreasing output as this may indicate urinary retention.

d. Instruct that drowsiness, dizziness and confusion may occur.

Warn patient not to exceed recommended dose.(Hodgson, 2013)

Right lower abdominal pain was manifested by the patient, partly attributed to the direct pressure from the tumor in her right ovary. The presence of the tumor irritates the nerve endings, causing prostaglandin stimulation resulting to the sensation of pain. Ketorolac (Toradol) and Tramadol (Ultram) mediate this cycle as they stop prostaglandin synthesis and inhibit reuptake of norepinephrine and serotonin, respectively. In addition, the medications were ordered to be administered intravenously for quicker absorption, thereby alleviating the pain promptly. The medications were meant to counter both the pain related to the disease process and the expected postoperative pain.

Table 13: Metoclopramide


January 13, 2015

1:00pm

Metoclopramide (Apo-Metoclop) 10 mg intravenously every six hours for nausea and vomiting

This drug is a dopamine antagonist that stimulates motility of upper GI tract, increases lower esophageal tone and blocks dopamine receptors at the chemoreceptor trigger zone.(Hodgson, 2013)

a. Report immediately the onset of restlessness, involuntary movements, facial grimacing, rigidity, or tremors.

b. Monitor BP carefully during IV administration.c. WARNING: Keep diphenhydramine injection

readily available in case extrapyramidal reactions occur (50 mg IM).

WARNING: Have phentolamine readily available in case of hypertensive crisis (most likely to occur with undiagnosed pheochromocytoma).(Hodgson, 2013)

Metoclopramide (Apo-metoclop) is a known antiemetic. It stimulates the motility of upper GI tract without stimulating gastric, biliary,or pancreatic secretions;appears to sensitize tissues to action of

20

acetylcholine; relaxes pyloric sphincter which, when combined with effects on motility, accelerates gastric emptying and intestinal transitthereby reducing the possibility of nausea and vomiting. Fluids

Table 14: Plain Normal Saline Solution (0.9% Sodium Chloride)

Fluid Description and Purpose Nursing Interventions or ConsiderationsPlain Normal Saline Solution (0.9% Sodium Chloride) 1L x 12 hours

September 9, 201410:40 PM

PNSS is a sterile, non-pyrogenic, isotonic solution for fluid and electrolyte replenishment. The fluid is used because it has little to no effect on the tissues. It replaces ECF and hydrates the client, preventing hypovolemic shock or hypotension. It is also compatible with blood. (Crawford, 2013)

- Calculate and maintain appropriate flow rate. Avoid hypervolemia.- Do not administer unless solution is clear and container is undamaged.- Discard unused portion.- Properly label the IV Fluid.- Observe aseptic technique when changing IV fluid.(Crawford, 2013)

Because the osmolality is entirely contributed by electrolytes, the solution remains within the ECF, so it does not cause red blood cells to shrink or swell. Since it is isotonic, it expands the ECF volume. It should be recalled her hemoglobin and hematocrit levels in the CBC results were borderline low; also, she was presenting nausea and vomiting that risks her towards developing electrolyte imbalance. With this reasons, administration of PNSS is appropriate. It helps prevent hyponatremia and hypochloremia, water overload, and mild metabolic acidosis that may happen as complications of her present condition. By and large, infusion of this fluid, which is the only one compatible with blood, is an appropriate intervention.

Table 15: Dextrose 5% in Lactated Ringer’s Solution

Fluid Description and Purpose Nursing Interventions or ConsiderationsDextrose 5% in Lactated Ringer’s Solution x 16 hours

January 9, 2015

6:30 pm

D5LRS contains sodium, chloride, potassium, calcium and lactate. Lactate is metabolized in the liver to form bicarbonate saline and balanced electrolyte solution commonly are used to restore vascular volume, particularly after trauma or surgery. It is a hypertonic solution that has an effective osmolality greater than the body fluids. This pulls the fluid into the vascular compartments by osmosis resulting in an increase in vascular volume.It also serves as a route for administration for intravenous medication


21

especially if the patient is for preoperative.(Crawford, 2013)

4 D5LRS bottles were given preoperatively to prevent electrolyte imbalance and to serve as fluid and caloric supply for the patient. It also serves as a route for administration for intravenous medication especially if the patient is for preoperative.Thereafter, 3 bottles of the same IVF were administered. LRS contains sodium, chloride, potassium, calcium and lactate. Lactate is metabolized in the liver to form bicarbonate saline and balanced electrolyte solution to restore vascular volume, particularly after surgery.

Table 16: Plain Normal Saline Solution

Fluid Description and Purpose Nursing Interventions or ConsiderationsPlain Normal Saline Solution x 24 hours

January 12, 2015

12:25 pm

Normal Saline is a sterile, non-pyrogenic solution for fluid and electrolyte replenishment. It contains no antimicrobial agents.It is indicated as a source of water and electrolytes. It is also for fluid and electrolyte replenishment as well as for medication administration. (Crawford, 2013)


1 bottle of PNSS was administered preoperatively after all the preceding D 5LRS bottles were consumed. Conversely, the patient was given another bottle of PNSS x KVO as a postoperative IVF solution. The patient responded well to the treatment and did not manifest any signs of dehydration of electrolyte imbalances. The patient had an effective fluid balance during the entire therapy.

Table 17: Blood Transfusion (PRBC)

Fluid Description and Purpose Nursing Interventions or ConsiderationsPacked Red Blood Cells (1 unit) x 4 hours

January 12, 2015

12:25 pm

A blood transfusion is a safe, common procedure in which you receive blood through an intravenous (IV) line inserted into one of your blood vessels.Blood transfusions are used to replace blood lost during surgery or a serious injury. A transfusion also might be done if your body can't make blood properly because of an illness.(Crawford, 2013)

- Assess laboratory values.- Verify the medical prescription.- Assess the client’s vital signs, urine output, and history of transfusion reaction.- Transfuse immediately after the blood product has been obtain from the blood bank.- With another registered nurse, verify the client’s name and number check blood compatibility, and note expiration time.- Stay with the client for the first 15 to 30 minutes of the infusion and continuously monitor the vital signs.- Strictly infuse the blood product at the prescribed rate.- When the transfusion is completed, discontinue infusion and dispose the bag and the tubing properly.

22

- Document all interventions done and observations seen.(Crawford, 2013)

It should be recalled that her RBC andhemoglobin and hematocrit levels in the CBC results were borderline low. It is noteworthy that she was ordered to undergo surgery the day after the ordered infusion of blood. It is known that surgery is a cause of major blood loss among all types of patients to undergo one. To help boost her red blood cells, administration of PRBC is appropriate. Thereafter, the patient responded well to the treatment and did not manifest any signs of blood transfusion reactions.

Surgery

Table 18: TAHBSO

Procedure Description and Purpose

Nursing Interventions

TAHBSO Total Abdominal Hysterectomy Bilateral Salpingo Oophorectomy (TAHBSO) is a surgical procedure in which the health care provider removes the uterus including the cervix and the ovaries including the fallopian tubes.It is performed to treat cancer of the ovary(s) and uterus, endometriosis, and large uterine fibroids.This surgery allows for the removal of as much of themass as possible. If cancerous, some may have spread to the nearby organs.To reduce the risk of spread, the surgeon removes surrounding organs as well. Hence, even though the tumour may have started on the ovary, that the uterus and tubes are also removed.(Hui, 2011)

Pre-admission Testing-Initiate initial preoperative assessment.-Initiate teaching appropriate to patient.-Verify completion of preoperative testing.-Verify understanding of surgeon-specific preoperative orders (e.g. bowel preparation, preoperative shower).-Complete preoperative assessment.-Verify that operative consent has been signed.Intraoperative Phase-Maintain aseptic, controlled environment.-Effectively manage human resources, equipment, and supplies for individualized patient care.-Position the patient: function alignment, exposure of surgical site.-Apply grounding device to patient.-Complete intraoperative documentation.Physiologic Monitoring-Calculate effect on patient of excessive fluid loss or gain.-Reports change in patient’s vital signs.Postoperative Phase-Report patient’s response to surgical procedure and anesthesia.-Describe physical limitations.-Determine patient’s immediate response to surgical intervention.-Monitor patient’s physiologic status.-Assess patient’s pain level and administer appropriate pain relief measures.-Maintain patient’s safety.Transfer to Surgical Unit/Ward-Continue monitoring of physical and psychological response to surgical intervention.-Provide teaching during immediate recovery period.-Assist in recovery and preparation for discharge home.

23

-Assist with discharge planning.(Hui, 2011)

It was noted that the client has given birth to 2 children already, and that the she is still in the child-bearing age. Teachings would matter in concerns regarding a 3-part recovery: physical, emotional, and sexual (Juravinski Cancer Center, 2010).

These 3 parts of the recovery period may happen at different times.Physical recovery includes healing of the skin incision and returnof energy. This can take 6 to 8 weeks. At the end of this time,most women will be back to their usual work and social activities (Juravinski Cancer Center, 2010).

Emotional recovery means adjusting to the shock of having cancer (this was confirmed through biopsy 3-4 weeks after), being away from home and believing one can become wellagain. It also means feeling comfortable with oneself and thechanges in the appearance of the body after surgery.Emotional recovery may happen at the same time as physicalrecovery, or it may take longer (Juravinski Cancer Center, 2010).

Sexual recovery involves a return to previous patternsof lovemaking, or making changes that fit with the partner’s and own needs. The outer sexual organs, the vagina and the brainremain the same. So does the normal, human need to feel loved and cared for.The length of time for this recovery varies, but it is possible withpatience and care. It can take 1 to 3 months, but it is not unusualfor it to take longer (Juravinski Cancer Center, 2010).

Most women report few sexual changes as a result of this operation.Healing of all incisions usually takes 6 to 8 weeks. After that, it ispossible to start having intercourse again. Of course, affection andtouching are possible before that time if the couple wishes.This surgery will not change the woman’s ability to havesatisfying sexual relations or change her level of interest in sex (Juravinski Cancer Center, 2010).

The vagina may be shorter in its relaxed state, if the topsection has been removed with the uterus. As the vagina isvery stretchy, most people cannot tell the difference during intercourse. In the “aroused” state, the vagina naturallylengthens (Juravinski Cancer Center, 2010).

Menopause and a cancer diagnosis can be stressful. If one hasbeen tired, anxious, or worried, she may find that her interestin sex is less. Talking to the partner or health care providersalong with time and patience shall be recommended to help sexualfeelings return. By 6 months, most women report a returnto their usual lovemaking (Juravinski Cancer Center, 2010).

24

NURSING DIAGNOSES

A. List of Problems as Prioritized

1. Imbalanced Nutrition: Less than Body Requirements2. Infection3. Acute Pain4. Constipation5. Risk for Deficient Fluid Volume6. Risk for Impaired Skin Integrity

Prioritizing care is an essential nursing skill which involves differentiating between problems needing immediate attention and those requiring subsequent action.

There are three levels of prioritization. The immediate first-level problem involves the emergency life-threatening and safety situations, for instance, those diagnoses that involve the airway, breathing, and circulation of the client. The second level concerns such things as mental status change, acute pain, acute urinary elimination, nutrition, and others. The third level priority includes those that do not fit into the other two categories. An example of this level includes knowledge deficit.

Imbalanced Nutrition: Less than Body Requirements is the top priority in the plan of care for the client since malnutrition is one of the greatest concerns for a patient with ovarian cancer (Martin, 2006). Nursing interventions for the patient include explaining the need for adequate consumption of carbohydrates, fats, protein, vitamins, minerals, and fluids (Carpenito, 2000). This is not an immediate first-level problem; nonetheless, this is the priority because all of the other enumerated diagnoses do not require immediate attention.

In cancer patients, infection is a priority. It is an expected complication of the immunosuppression that happens as cancer cells spread throughout the surrounding involved structure (in this case, the right ovary). It is a priority because as if this particular complication is left not intervened, return to normal health could not be achieved. It is imperative then that the patient’s immune system is protected against harmful organisms (such as bacteria, viruses, and fungi) that may aggravate the present condition.

Increased uterine muscle contractility causing an increase in lactic acid formation irritates the nerve, resulting to the abdominal pain experienced by the client. One of the primary functions of an efficient and effective nurse is to promote comfort for the client.

Plans of care for constipation and impaired skin integrity follow. The former problem is common among ovarian cancer patients as there large intestine become compromised by the increasing size of peritoneum leading to decrease in peristalsis (Smeltzer, 2011). The latter is attributed to the presence of surgical incision site as incurred during the TAHBSO. Preventing skin breakdown is a must to prevent infections that may further complicate the present condition of the client.

A potential diagnosis is generally a lower priority; however, it is still dependent on the condition of the client. In this case, although fluid deficit has not actually occurred yet, it can have a positive effect

25

to some of the other diagnoses when addressed. Moreover, these can lead to complications when the interventions are delayed.

26

Date ASSESSMENT (Problem Statement/Nursing Diagnosis) Nursing Care Plan (Objective Goal)January 15,

2015Imbalanced Nutrition: Less than body requirements related

to decreased appetite as evidenced by weakness and a marked decrease in body weight

After 5 hours of nursing interventions, the client will verbalize understanding of interferences to adequate intake and have a

Individual Problem (CUES)Subjective:“Medyoagkakapsotakngemhaankotalagangamaibusdyaykankanek.”

Objective:>consumes 50% of meals served

>weight loss of about 10 kilograms over a month period (from 54kg to 43 kg as claimed)

>BMI: 18.61 kg/m2

IMPLEMENTATIONAPPROACHES RATIONALE

27

>Monitor daily food intake and explore attitudes toward eating and food.

>Ascertain amount of recent weight loss. Weigh daily or as indicated.

>Observe for weakness, pallor, delayed wound healing, and brittleness of nails.>Promote a pleasant environment for eating with company if possible.>Offer small frequent feedings as indicated.

>Provide balanced diet with individually appropriate protein, complex carbohydrates, and calories.

>Administer vitamin/mineral supplements (multivitamin + ferrous sulfate) in between meals as ordered.>Encourage use of relaxation techniques, moderate exercise before meals, with adequate fluid intake.

>Daily food intake identifies nutritional strengths or deficiencies and many psychological, physiological, and cultural factors determine the types, amount, and appropriateness of food consumed.>If these measurements fall below minimum standards, client’s chief source of stored energy (fat tissue) is depleted.>Helps in identification of protein-calorie malnutrition, especially when weight is less than normal.>Eating is in part a social event, and appetite can improve with increased socialization.>Decreased gastric motility causes client to feel full and reduces intake. Offering small frequent feedings may compensate for the decreased consumption during major meals of the day. >Adjustments may be needed to deal with the body’s decreased ability to process protein, as well as decreased metabolic rate and levels of activity. >Supplements can play an important role in maintaining adequate caloric and protein intake.>Promotes sense of well-being and may improve appetite. Metabolic

28

tissue needs are increased by fluids.

ACTUAL OUTCOME Date & Time Resolved“Sige ta ipapatiknganayunantikanen, uraytig-ba-bassitlang,” able to verbalize

understanding on the presented interventions to adequate food intake.January 15, 2015 1:00 PM

NAME OF PATIENT: Patient Ova ADMITTING DIAGNOSIS: G2P2 (2002) Ovarian New Growth probably malignancyADDRESS: Baguio AGE: 25 SEX: F DATE ADMITTED: January 9, 2015


2015Infection related to suppressed inflammatory response. After 2 days of nursing interventions, the client will be

able to participate in interventions to reduce risk of infection.

Individual Problem (CUES)

29

Objective:>appears weak>status post TAHBSO>leukocyte and neutrophil count above normal>presence of pus cells and bacteria in the urine (as indicated in the urinalysis result)


30

>Examine general condition and laboratory results.

>Assess wound appearance.>Check tension of dressings. Apply tape at the outer margin of dressing of incision. Avoid wrapping or covering the affected area with tape.>Perform aseptic dressing changes. Keep wounds clean and dry.>Cleanse wound and skin surface (if needed) with NSS and betadine solution.>Stress to avoid vigorous rubbing and scratching and to pat skin instead of rubbing when itchiness can no longer be tolerated.>Emphasize importance of frequent hand hygiene and also to the family members.

>Provides information regarding external and internal problems that may be associated with the presence of infection.>Red swollen draining incision is indicative of infection.>Prevent tape skin abrasions. Covering most of the area using tape can impair/occlude circulation to wound.

>This is to avoid introducing infectious organisms to the site thus preventing further spread of infection.>Aids in removal of drainage/exudates (if present) and in the reduction of skin contaminants.>Rubbing and scratching can cause further injury and delay healing. It helps prevent skin friction/trauma to sensitive tissues.>Hand hygiene is an important method in reducing spread of microorganisms, thereby lessening occurrence of contamination.

ACTUAL OUTCOME Date & Time ResolvedAble to demonstrate techniques on how to prevent skin breakdown. January 15, 2015 2:30 PM



2015Acute pain related to inflammatory process as evidenced by

guarding behavior.After 3 hours of nursing interventions, pain will be reduced to 3/10.


31

Subjective:“Nagsakitditoybandatiayantitumorko.”

Objective:>Pain rated as 8/10>Pain described as sharp, localized at the right lumbar area, which lasts for about 20-30 minutes with half-hour intervals. It is aggravated when lying on the affected side and when exposed to cold. >Grimacing>Guarding behavior>Restlessness


32

>Assesscharacteristics of pain: quality, location, duration, and aggravating factors.>Observe for nonverbal cues and pain behaviors.

>Respond immediately to complaint of pain and assist to a comfortable position.

>Monitor vital signs.

>Eliminate additional stressors or sources of discomfort whenever possible. >Give analgesics (ketorolac 30 mg via IV route) as ordered.

>Instruct in the use of relaxation techniques such as deep breathing exercises and diversional activities such as socialization with others and reading newspapers.>Provide rest periods to facilitate comfort, sleep, and relaxation.>Encourage the patient to evaluate and report effectiveness of measures used.

>A good assessment of pain will help in the treatment and ongoing management of pain.>Observations may or may not be congruent with verbal reports or may be the only indicator present when client is unable to verbalize.>Prompt responses to complaints may decrease anxiety. Demonstrated concern for client’s welfare and comfort fosters the development of a trusting relationship.>Vital signs are usually altered in pain. Tachycardia, elevated blood pressure, tachypnea, and fever may accompany pain.>Patient may experience an exaggeration in pain or a decreased ability to tolerate painful stimuli. >Analgesics provide for adequate control of pain and inflammation, and reduces muscle tension which improves client comfort and promotes healing.>These refocus the client’s attention and reduces tension.

>Experiences of pain may become exaggerated as the result of fatigue.>Pain relief strategies can be modified to promote more satisfactory comfort levels.

ACTUAL OUTCOME Date & Time Resolved“Medyonasakitpaylangngem kayak met,” rated pain as 4/10. January 15, 2015 11:00 PM



2015Constipation related to abdominal muscle weakness as

evidenced by hypoactive bowel sounds.After 5 hours of nursing intervention, client will be able to

establish normal patterns of bowel functioning.

33


Subjective:“Haanaktalagatinmak-takimanipud pay idi last Wednesday.”

Objective:>hypoactive bowel sounds>urge to defecate as claimed>firm abdomen


34

>Auscultate bowel sounds. Note abdominal distension.

>Note frequency of the stool passage and reason for problem, rule out medical causes e.g., cancer and bowel obstruction.

>Assist client with sitting on edge of the bed or walking. Institute bowel retraining and regular or ROM exercise as tolerated.>Provide small frequent feedings, meals of foods high in residue (if not contraindicated), maintaining needed protein and carbohydrates such as bland cooked vegetables (e.g., carrots and beans).>Encourage adequate fluid intake (2-3L/day and increase fiber in diet.)

>Large intestine is being compromised by the increasing size of the peritoneum which may cause narrowing of the rectum and decrease peristalsis resulting to constipation.>Provides a baseline for comparison, promotes recognition of changes. Identification of underlying medical condition is necessary to achieve optimal bowel function.>Ambulation helps stimulate intestinal function and peristalsis. Loss of muscle tone reduces peristalsis or may impair control of rectal sphincter.>Promotes gastric stimulation. Use of high-fiber foods can increase peristalsis, thereby promoting defecation. Furthermore, it improves stool consistency and promotes evacuation.>May reduce constipation by improving stool consistency and stimulating peristalsis.

ACTUAL OUTCOME Date & Time Resolved“Sigekitak man ta aramidekdayta”; able to establish appropriate interventions related to bowel promotion.

January 15, 2015 1:00 PM



2015Impaired skin integrity related to presence of surgical

incision.After 8 hours of nursing interventions, client will be able to demonstrate techniques to prevent skin breakdown.


35

Subjective:“Nagatelngaydaytoysugatkoditoy (pointing to incision site).”

Objective:>Incision site at the hypogastric area (incurred from recent TAHBSO)>with minimal blood noted on surgical dressing>BMI: 18.61 kg/m2

>pinkish 5.5-inch incision site, with no signs of inflammation


36

>Examine the area for bleeding and discoloration.

>Assess current nutrition and wound appearance.

>Check tension of dressings. Apply tape at the outer margin of dressing of incision. Avoid wrapping or covering the affected area with tape.

>Perform aseptic dressing changes. Keep wounds clean and dry.>Cleanse skin surface (if needed) with NSS and betadine solution at the incision area.>Splint abdominal area with pillow or pad during coughing or sneezing or when moving.

>Instruct to avoid vigorous rubbing and scratching and to pat skin instead of rubbing.

>Provides information regarding skin circulation and bleeding tendencies.

>Inadequate nutrition intake places individuals at risk for skin breakdown and it compromises healing. Red swollen draining incision is indicative of infection.>Prevent tape skin abrasions. Covering most of the area using tape can impair/ occlude circulation to wound.

>This is to avoid introducing infectious organisms to the site thus preventing infection.>Reduces skin contaminants; aids in removal of drainage/exudate.>Equalizes pressure on the wound, minimizing risk of dehiscence-especially important during healing stage and for incisions secured with adhesive tapes at the edges.>Rubbing and scratching can cause further injury and delay healing. It helps prevent skin friction/trauma to sensitive tissues.

ACTUAL OUTCOME Date & Time ResolvedAble to demonstrate techniques on how to prevent skin breakdown. January 15, 2015 2:30 PM



2015Risk for deficient fluid volume related to inadequate fluid

intake.Within 8 hours of nursing interventions, client will have an oral fluid intake of 1500-2000mL of fluids as tolerated.

37


Subjective:“Haanakunayngaag-ininumtidanum.”

Objective:>good skin turgor>dry skin and lips>drank 2 cups (about ½ L) of fluid within the shift>on DAT (diet as tolerated)>output during the shift: 400 mL>urine is dark-yellow and turbid (according to the urinalysis report)


38

>Assess skin turgor and oral mucous membrane.

>Observe for bleeding tendencies; e.g., oozing from mucous membranes, puncture site; presence of ecchymosis or petechiae.>Evaluate nutritional status, noting current oral fluid intake and type of diet. > Monitor input and output balance.

>Monitor vital signs.

>Assess color and amount of urine.>Assist to the comfort room.

>Provide oral care.

>Maintain accurate drip rate of IVF solutions being infused.

>Encourage to increase oral fluid intake up to 3000 mL per day and to increase intake of fluid-rich foods such as watermelon.>Explain importance of rehydration.

>This is done to assess the level of dehydration. Indirect indicators of hydration status/ degree of deficit.>Early identification of problems (which may occur as a result of cancer or therapies) allows for prompt intervention.>Problems concerning presence of injury and immobility can negatively affect fluid intake.>This provides another means of assessing fluid balance and ensures an accurate picture of fluid status.>Blood pressure, heart rate, and respiratory rate often increase initially when fluid deficit is present. >Concentrated urine denotes fluid deficit.>Dehydration poses risk for dizziness; hence, this intervention ensures safety.>This helps decrease the discomfort from dry mucous membrane. This may also promote the client’s interest in drinking.>To deliver fluids accurately and at desired rates to prevent either under- or overinfusion.>This promotes the rehydration of the client.

>This gives information and enhances compliance and cooperation.

ACTUAL OUTCOME Date & Time ResolvedNormal skin turgor, oral fluid intake of 1,500 mL, and urine output of 1,300 mL. January 15, 2015 2:30 PMNAME OF PATIENT: Patient Ova ADMITTING DIAGNOSIS: G2P2 (2002) Ovarian New Growth probably malignancyADDRESS: Baguio AGE: 25 SEX: F DATE ADMITTED: January 9, 2015

39

DISCHARGE PLAN

This is the case of patient X, a 25-year-old married woman, Christian, admitted on January 9, 2015. She was diagnosed with G2P2 (2002) ovarian new growth, right, probably immature cystic teratoma, rupture, cannot totally rule out immature cystic teratoma by rush frozen section, carcinomatosis peritoneal, previous uterine scar 2x for cephalopelvic disproportion.

CRITERIA HEALTH TEACHINGA. Diet Encourage patient on the following:

A. The inclusion of protein rich foods in her diet such as lean meat, egg and fish to promote wound healing.B. An increased intake of vitamin C rich foods such as oranges and guavas to boost immunity and prevent infection.C. Increase oral fluid intake up to 3 liters per day.

B. Activities Instruct patient on the following:A. Exercise should include walking at quick pace for 15 to 20 minutes for four to five days a week and once or twice a week at a slower pace for 20 to 25 minutes.B. To avoid straining at the incisionsite, liftingof anything heavier than 20 pounds for 4 to 6 weeks after surgery should be contraindicated.C. advise to walk as often as possible and as tolerated.

C. Medications

Clindamycin

Naproxen Sodium

A. Follow the schedule of medication.B. Continue coughing and deep breathing exercises as taught in the hospital.

- It is important to take this medication on time and to finish all of them as prescribed even when improvement in condition is observed prior to the prescribed duration of intake. Non-compliance may predispose the bacteria to developing resistance to the drug. One capsule is taken three times a day, at 8 am and 6 pm, or before or after breakfast and dinner.

- Advise to take this medication with a full glass of water and to remain in an upright position for 15–30min after administration. It may be taken with food or milk to prevent nausea. Explain

40

Bisacodyl suppository

that this is used to decrease swelling and pain or fever. One tablet should be taken three times a day, after breakfast, lunch, and dinner.

- This is used for occasional constipation. Inform the patient that is for rectal use only. Instruct to watch out for abdominal discomfort, faintness, feeling of rectal burning, and mild cramps.

D. Out-patient Follow-up Advise patient to visit hospital or a physician when:A. Severe pain that does not diminish after pain management is experienced.B. Fever, swelling and purulent discharge at the incision area are observed.

Inform the patient to come back at the OPD on January 23, 2015 for follow-up check-up.

E. Others

Wound care A. Keep the wound clean and dry and avoid touching the wound. Regularly clean it with betadineand change the dressing. Wash hands before and after handling the wound.B. Change the bandages any time they get wet or dirty. C. Inspect the incision site every day for redness, drainage, swelling, or separation of the skin.D. Advise against use oils, powders, lotions, or creams on the incision.

The patient was discharged on January 16, 2015 after 7 hospital days. She went home with improved condition, ambulatory and accompanied by relatives.

41

CONCLUSION AND RECOMMENDATIONS

Every individual aspires to be as healthy as they possibly can, but as it turns out, life is not that simple.

At age 25, Patient Ovawas diagnosed with ovarian new growth (right), which prompted her to undergo Total Abdominal Hysterectomy with Bilateral Salpingooophorectomy (TAHBSO). A biopsy was performed simultaneously which later revealed a positive result, confirming the malignancy of the tumor.

Dubbed as a “silent killer,” ovarian cancer is one of the leading causes of cancer deaths in women. It usually goes undetected until the disease has advanced and the chances of remission are poor. For this reason, early detection is important. Fortunately, in the case of Patient Ova, the tumor was removed (along with the organs surrounding it) before it had the chance to metastasize.

As part of the health care team, we cannot ensure the complete recovery of patients from such conditions. We can, however, promote ways for increased comfort, faster healing, and efficient rehabilitation of the client through comprehensive health education and holistic nursing care.

Anchored on the findings of this case study, several recommendations were derived.

Patients are encouraged to be knowledgeable about their condition and to keep abreast of new developments in the field. The more the client knows about ovarian cancer, the easier it will be for her to accept the condition, control the disorder, and live a normal productive life.

The client, Patient Ova, should follow up with her physician regarding surgery and post-cancer treatment, as scheduled. Fitch and Turner (2006) have pointed out that nurses can teach patients how to advocate for themselves with their healthcare providers by helping them formulate and write down questions about their treatment to bring to appointments and by encouraging them to bring a supportive person with them to their medical appointments.

As regards her diet, the client should also follow up with a nutritionist to find means to gain weight. Christensen (1999) has claimed that dietary treatment should create both a positive energy and a nitrogen balance in the underweight patient, and advised that high kilocalorie and high-protein diets can provide this in frequent small-volume meals. This is seconded by Martin (2006) who advised supplying small, frequent meals served at room temperature, as well as the use of nutritional supplements.

The family plays an important role in the client’s illness and recovery. Their physical and emotional presence should be afforded for the client to feel their support and concern. They are encouraged to be the client’s source of strength and inspiration as she undergoes distressing procedures. In addition, it is important that they are oriented and educated on the facts regarding the client’s condition and various treatment options. This will enable them to understand what the client needs, may it be physical, emotional, or spiritual, and be able to competently respond to such needs. Upon grasping the significance of the importance, they shall then be expected to work hand-in-hand with the health care workers for a better and more efficient delivery of care.

42

Student nurses are encouraged to equip themselves with the necessary knowledge and skills that will enable them to render quality and holistic nursing care and interventions. They play an important role in helping the client and family implement healthy behaviors and help them monitor the client’s health. Moreover, they must develop patience, love for work, and empathy for their clients.

When venturing on a case, it is recommended that student nurses must personally and truly face and care for the subject so that the remarkable experience could be shared authentically. They are also encouraged to continue studying different cases and to impart these to other student nurses, clients, and their significant others.

43

REFERENCES

Allan, A. L. (2011). Cancer Stem Cells in Solid Tumors. Springer Science & Business Media.

American Cancer Society. (2015, January 3). Retrieved February 13, 2015, from www.cancer.org: http://www.cancer.org/cancer/ovariancancer/detailedguide/ovarian-cancer-what-is-ovarian-cancer

American Cancer Society. (2014). Retrieved 1 22, 2015, from http://www.cancer.org/cancer/ovariancancer/detailedguide/ovarian-cancer-risk-factors

Behtash, N. e. (2008). Ovarian carcinoma associated with pregnancy. BMC Pregnancy and Childbirth, 8.Juravinski Cancer Center (2010). Recovering from total abdominal hysterectomy - bilateral salpingo-oophorectomy and omentectomy . Ontario: Hamilton Health Sciences,.

Bohnenkamp, S., LeBaron, V., & Yoder, L. (2007). The medical-surgical nurse’s guide tocancer: Part I.Medsurg Nursing, 16 (4), p.259-265.

Cervical Cancer: Understanding your diagnosis. Canadian Cancer Society 2013.

Christensen, B., &Kockrow, E. (1999). Foundations of nursing (3rd ed.). St. Louis: Mosby.

Cramer, D. W., Liberman, R. F., Titus-Ernstoff, L., Welch, W. R., Greenberg, E. R., Baron, J. A. and Harlow, B. L. (1999), Genital talc exposure and risk of ovarian cancer. Int. J. Cancer, 81: 351–356. doi: 10.1002/(SICI)1097-0215(19990505)81:3<351::AID-IJC7>3.0.CO;2-M

Crawford, A. (2013). I.V. fluids: What nurses need to know. Nurse, 41(5), 30-38.

Farghaly, S. A., (2014) Novel Targeted Therapies for Patients with Ovarian Cancer. J Cancer SciTher 6:e133. doi: 10.4172/1948-5956.1000e133

Fitch, M., & Turner, F. Ovarian Cancer. (2006). Canadian Nurse, 102(1), p. 18-19.

Foundation for Women’s Cancer. (2011). Chicago: Morphotek, Inc.Mayo Clinic. (2014, May 14). Retrieved January 29, 2015, from http://www.mayoclinic.org/tests-procedures/chest-x-rays/basics/definition/prc-20013074

Hodgson, B. (2013). Saunders Nursing Drug Handbook . Elsevier Health Sciences .

Huether S. and McCance, E. ( 2011 ). Understanding Pathophysiology 5th edition. Elsevier Health Sciences.

Hui, D. (2011). Approach to Internal Medicine: A Resource Book for Clinical Practice. Springer Science & Business Media.

Ignatavicius, D., & Workman, M. (2006). Medical-surgica nursing (5th ed.). St. Louis: ElsevierSaunders.

Larsson, L. H. (2004). Fruit and vegetable consumption in relation to ovarian cancer incidence: the Swedish mammography cohort. British Journal of Cancer.

44

Larsson, S. B. (2004). Milk and lactose intakes and ovarian cancer risk in the Swedish. USA: The American Journal of Clinical Nutrition.

Martin, V. (2006).Shining a light on ovarian cancer, the hidden tumor. Nursing Made Incredibly Easy, 4(6), p.28-37.

MedicineNet. (2014, January 29). Retrieved February 18, 2015, from MedicineNet.com: http://www.medicinenet.com/ca_125/article.htm

MedicineNet. (2015, February 2). Retrieved February 26, 2015, from MedicineNet.com: http://www.medicinenet.com/electrocardiogram_ecg_or_ekg/article.htm

Pagana KD, Pagana TJ. Ultrasound studies. In: Mosby’s Manual of Diagnostic and Laboratory Tests (Pagana KD, Pagana TJ, Eds), Mosby, St Louis, 1994; pp 787- 791

Siamak N. Nabili, M. M. (2014, June 12). eMedicineHealth. Retrieved January 30, 2015, from eMedicineHealth.com: http://www.emedicinehealth.com/urinalysis/article_em.htm

Stewart DE, Duff S, Wong F, Melancon C, Cheung AM. The Views of Ovarian Cancer Survivors on Its Cause, Prevention, and Recurrence.MedGenMed 3(4).

Sood AK, Bhatty R, Kamat AA, Landen CN, Han L, Thaker PH, et al. Stress hormone-mediated invasion of ovarian cancer cells. Clin Cancer Res 2006;12:369–75

Vasilev F, Chun JT, Gragnaniello G, Garante E, Santella L (2012) Effects of Ionomycin on Egg Activation and Early Development in Starfish. PLoS ONE 7(6): e39231. doi:10.1371/journal.pone.0039231

World Health Organization Web site. http://www.who.int/cancer/resources/ incidences/en/. Accessed November 4, 2008.

Date post:	17-Jan-2016
Category:	Documents
Upload:	rencel-finnos-sabog
View:	33 times
Download:	0 times

Case Study Final

Documents