CERVICAL CANCER

(STAGE III)

A CASE PRESENTATION

Presented to:

LYNUEL R. SANTILLANA, RN, USRN, MAN

Presented by:
Ali, Amani C.
Cantero, Anne Francis M.
Dimalawang, Goldie
Enguito, Ena Rica
Fortich, Zeth Jehann
Galgo, Christine Alaiza
Lawanza, Hanin
Logarta, Zhybil
Metillo, Engelan
Omamalin, Jealin Claire
Unte, Nornihaya

SEPTEMBER 2017

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CASE CONTENTS

TITLE PAGE
Acknowledgement 3

Introduction 4

Review of Related Literature 5

Patients Health History 7

Diagnostic and Laboratory Procedures 11

Laboratory Results 12

Human Anatomy and Pathophysiology 13

Pathophysiology (Narrative Form) 21

Pathophysiology (Diagram Form) 22

Drug Study 26

Priority Nursing Diagnosis 33

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 ACKNOWLEDGMENT

As the presentors of this group case presentation, with deep appreciation and heartfelt
gratitude, we would like to acknowledge the following people who have supported us and made
this study a successful one:
To our parents who morally and financially supported us. For their encouragement and
understanding why were always late in coming home.
To our clinical instructor who undoubtedly imparted their knowledge and shown their
support to us.
To all staff Gregorio Lluch Memorial Hospital in OB-Gyne Ward, who gave us the permit
to copy all the information necessary for this educational output to be completed from the
patients chart.
To the patient and patients family who never ceased to answer whatever questions we
have raised.
And most especially, to our Heavenly Father for giving us all the blessings, strength,
wisdom and enlightenment that we are able to complete all the information needed.
Indeed, this case study has definitely enhanced and advanced our knowledge in our
chosen career.

THE PRESENTORS

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 INTRODUCTION

According to the Filipino cancer registry annual report, cervical cancer is the second most
common malignancy and is the most common cause of cancer-related mortality among Filipino
women. Although considered as a preventable disease, the burden of cervical cancer in the
Philippines remains to be moderately high, where the cost of nationwide organized cytology
screening has been a significant limitation. In a country where existing health infrastructure is
not sufficiently developed to support cytology-based screening program, the use of alternative
screening modalities, such as visual inspection of the cervix aided by acetic acid (VIA) with or
without magnification, is currently under evaluation. In addition, prophylactic Human
Papillomavirus (HPV) vaccination for the prevention of infection and related disease is being
considered as an additional cervical cancer control strategy.
Cervical cancer is the term for a malignant neoplasm arising from cells originating in the
cervix uteri. One of the most common symptoms of cervical cancer is abnormal vaginal
bleeding, but in some cases there may be no obvious symptoms until the cancer has progressed
to an advanced stage. Treatment usually consists of surgery (including local excision) in early
stages, and chemotherapy and/or radiotherapy in more advanced stages of the disease.
Patient CE, 48 years old, a resident of Suarez, Iligan City was admitted at GTLMH for
complaints of vaginal bleeding on August 18, 2017. She was diagnosed with Stage 3 Cervical
Cancer.
There were an estimated 530 000 cases of cervical cancer and 275 000 deaths from the
disease in 2008. It is the third most common female cancer ranking after breast (1.38 million
cases) and colorectal cancer (0.57 million cases). The incidence of cervical cancer varies widely
among countries with world age-standardized rates ranging from <1 to >50 per 100 000. Cervical
cancer is the leading cause of cancer-related death among women in Eastern, Western and
Middle Africa; Central America; South-Central Asia and Melanesia. The highest incidence rateis
observed in Guinea, with 6.5% of women developing cervical cancer before the age of 75 years.
India is the country with the highest disease frequency with 134 000 cases and 73 000deaths.
Cervical cancer, more than the other major cancers, affects women <45 years.
Worldwide, more than 238,000 women die each year from cervical cancer; over 80
%these women live in developing countries (2). In the Philippines, cancer ranks third among the
leading causes of morbidity and mortality. Cervical cancer is the 2nd most common type of
cancer in women, next only to breast cancer. The incidence of cervical cancer in the Philippines
has remained unchanged since 1980, with an overall survival rate of 51.7 %, or about 10
per100,000 women dying from the disease over 5 years. In 2005, an estimated 7,277 new cases
and3,807 deaths will occur (3) in that country. About two-thirds of cervical cancer cases in the
Philippines are diagnosed at an advanced stage; owing to inadequate radiotherapy facilities in the
country, mortality is high.
The lack of knowledge and information about Cervical Cancer is one of the reasons why
we chose this case. Not many Filipino women know about the disease, that it is preventable and
can be cured when detected at the onset. We strongly believe that this case study will be very
helpful in our career someday as future registered nurses.
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 REVIEW OF RELATED LITERATURE

The function of the cervix is to allow flow of menstrual blood from the uterus into the
vagina, and direct the sperms into the uterus during intercourse. The opening of the cervical
canal is normally very narrow. However under the influence of the body hormones and the
pressure from the fetal head, this opening widens to about 4 inches (10 cm.) during labor, to
allow the birth of a baby. If the opening is loose, as observed in some women, it can lead to
miscarriages during pregnancy.

DEFINITION
Cervical cancer is the term for a malignant neoplasm arising from cells originating in the cervix
uteri. One of the most common symptoms of cervical cancer is abnormal vaginal bleeding, but in
some cases there may be no obvious symptoms until the cancer has progressed to an advanced
stage. Cancer screening using the Pap smear can identify precancerous and potentially
precancerous changes in cervical cells and tissue. Treatment of high-grade changes can prevent
the development of cancer in many victims. In developed countries, the widespread use of
cervical screening programs has reduced the incidence of invasive cervical cancer by 50% or
more.
RISK FACTORS
Exposure to human papillomavirus
Multiple sex partners
Early age at first intercourse
Sex with a promiscuous partner
History of sexually transmitted diseases
Family history of cervical cancer
Low socioeconomic status
Smoking and exposure to secondhand smoke
Multiple pregnancies or early childbearing
Long-term contraceptive use

CAUSES
The causes for cervical cancer are not clearly understood, however, Human Papilloma Virus
(HPV) infection is strongly associated with it. An infection of the Human Immuno-deficiency
Virus (HIV) increases the susceptibility to develop cervical carcinoma. Other risk factors:
Age:
Cervical cancer affects mostly the middle-aged, and is seen rarely in women below15years.
Smoking:
Cigarette smoking women are at twice the risk of developing cervical cancer in comparison to
non-smokers.
Race:
Certain races and ethnic groups like African- American, Hispanics and Native Americans are
genetically predisposed to develop cervical cancer.
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Promiscuity:
Having multiple sex- partners or having a partner, who is promiscuous, increases the chances of
developing cervical cancer.
STD:
A history of a sexually- transmitted disease makes a woman susceptible to develop cervical
cancer.
Reproductive History:
Having seven or more number of full- term pregnancies predisposes a woman to develop cervical
cancer.
Oral Contraceptives:
Long -term use of oral contraceptives makes a woman more prone to develop cervical cancer.

SIGNS AND SYMPTOMS

Early cervical cancers usually don't cause symptoms. When the cancer grows larger, women may
notice one or more of these symptoms:
Abnormal vaginal bleeding
Bleeding that occurs between regular menstrual periods
Bleeding after sexual intercourse, douching, or a pelvic exam
Menstrual periods that last longer and are heavier than before
Bleeding after going through menopause
Increased vaginal discharge
Pelvic pain
Pain during sex

Infections or other health problems may also cause these symptoms. Only a doctor can tell for
sure. A woman with any of these symptoms should tell her doctor so that problems can be
diagnosed and treated as early as possible.

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 PATIENT HEALTH HISTORY

A. Biographic Data
Name of Patient: Cornelia Tawagin
Age: 48 years old
Sex: Female
Date of Birth: November 21, 1963
Place of Birth: Suarez, Iligan City
Address: Suarez, Iligan City
Religion: Catholic
Nationality: Filipino
Civil Status: Married
Occupation: Nanny
Weight: 41 kgs.
Height: 410

B. Admission Data
Name of Hospital: Gregorio T. Lluch Memorial Hospital
Ward Service: OB-Gyne Ward
Date of Admission:September 18, 2017
Time of Admission: 5:45pm
Mode of Admission: Wheel chair
Admitting Physician: Dr. Flores
Attending Physician: Dr. Flores
Date and Time of clinical encounter: September 24, 2017

C. Vital Signs upon Admission

Temperature: 37.1 C
Heart rate: 84 bpm
Respiratory rate: 60 cpm
Blood Pressure: 120/80 mmHg

D. Vital Signs upon Assessment

Temperature: 36.4 C
Heart rate: 118 bpm
Respiratory rate: 20 cpm
Blood Pressure: 110/60 mmHg

E. Chief Complaint
(+) Vaginal Bleeding

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 F. Sources of Information
The primary source of information is the patient. The secondary source of data is the patients
chart.

G. Admitting Impression
Cervical CA

H. Final Diagnosis
Stage 3 Cervical CA

HISTORY OF PRESENT ILLNESS

A month prior to admission, the patient claimed that she noticed a foul smelling heavy vaginal
bleeding. But she refused to be brought to the hospital upon thinking of observing first her
condition for a month. She quitted her job, took a rest and prayed that the bleeding would
subside. So accompanied by her family, she was rushed to Gregorio T. Lluch Memorial Hospital.

PAST HEALTH HISTORY

The patient claimed that her first menarche occurred when she was 14 years old. Her
menstruation takes 1 week regularly and she can consume 2 sanitary pads per day. She claimed
that she used artificial method of family planning (control pills). Her first pregnancy was last
1996 and delivered the baby normally (NSVD) as well as her 2nd, 3rd, and 4th baby.
She also claimed that during the time she experienced heavy vaginal bleeding, she can consume
2 adult diapers per day and the color of her discharges is reddish and has a foul odor with watery
substances. Since the start of her foul-smelling vaginal discharges, she refuses to have her
husband sleep next to her. She never had any screening tests like Pap smear.

FAMILY HEALTH HISTORY

The patient claimed that she doesnt know about the causes of her parents and grandparents
death both paternal and maternal side.

Legend:
Female
Male
Deceased
Patient

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LIFESTYLE
Personal Habits
Early in the morning as she wakes up after grooming herself, she performs household chores.
She used to drink alcoholic beverages every time she had sleeping difficulties.
Diet
Before Hospitalization: the patient claimed that she eats 3 times a day in small amounts. She is
fond of eating dried salted fish, rice, and corn. She drinks 4-6 glasses of water every meal and
can consume more than one liter of water in a day. She has no special diet and no known food
allergies.
During Hospitalization: she still eats 3 times a day. Her diet is as tolerated. She eats anything of
what are being provided by the hospital.
Sleep and Rest Pattern
Before Hospitalization: the patient normally sleeps at 9:00 pm but often times had a hard time to
get a good sleep due to external factors. She usually wakes up at 6:00 am.
During Hospitalization: the patient stated that she usually sleeps at 10:00 pm and wakes up at
around 6:00 am.
Elimination Pattern
Before Hospitalization: the patient voids orange-colored urine several times a day and claimed
that she had not experienced any difficulties in urination. She also claimed that she usually
defecates once daily with brown, formed or semi-solid stool depending on the amount of food
taken.
During Hospitalization: still she urinated several times in a day with orange-colored urine but
having a foul odor. She defecates twice in a week with brown, formed or semi-solid stool.
Activities of Daily Living (ADL)
Before Hospitalization: the patient had no difficulties in performing the basic activities such as
grooming, locomotion and performing household chores.
During Hospitalization: the patient still performed few of the basic activities specifically
grooming, dressing and toileting but had difficulty moving due to presence of IV cannula
inserted at her right arm.

PHYSICAL CHANGES OF MIDDLE AGED ADULTS

Appearance Hair begins to thin and gray hair appears. Skin turgor and moisture
decrease, subcutaneous fat decreases, and wrinkling occur. Fatty tissue is
distributed, resulting in fat deposits in the in the abdominal area.

Musculoskeletal Skeletal muscle bulk decreases at about age 60. Thinning of the
System intervertebal discs a decrease in height of about 1 inch. Muscle growth
continues in proportion to use.

Cardiovascular Blood vessels lose elasticity and become thicker.

System

Sensory Visual acuity declines. Auditory acuity for high sounds decreases

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Perception particularly in men. Taste sensation also diminished.

Metabolism Metabolism slows, resulting in weight gain.

Gastrointestinal Gradual decreases in tone of large intestine may predispose the

System individual to constipate.

Urinary System Nephron units are lost during this time and glomerular filtration rate
decreases.

Sexualty Hormonal changes takes places, menopause.

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 DIAGNOSTIC AND LABORTATORY PROCEDURES

Chest X-rays- X-rays often can show if cancer cells have spread to the lungs.
CT Scan- An x-ray machine linked to a computer takes a series of detailed pictures of
your organs. A tumor in the liver, lungs, or elsewhere in the body can show up on the CT
scan. You may receive contrast material by injection in your arm or hand, by mouth, or by
enema. The contrast material makes abnormal areas easier to see.
Dilation and curettage (D&C)- a procedure to remove tissue from inside your uterus.
Doctors perform dilation and curettage to diagnose and treat certain uterine conditions
such as heavy bleeding or to clear the uterine lining after a miscarriage or abortion.
Complete blood count (CBC)- a blood test used to evaluate your overall health and
detect a wide range of disorders, including anemia, infection and leukemia.
Platelet count- a lab test to measure how many platelets you have in your blood.
Platelets are parts of the blood that helps the blood clot. They are smaller than red or
white blood cells.

Urinalysis- used to detect and manage a wide range of disorders, such as urinary tract
infections, kidney disease and diabetes. Involves checking the appearance, concentration
and content of urine. Abnormal urinalysis results may point to a disease or illness.
Pregnancy Test- designed to tell if your urine or blood contains a hormone called human
chorionic gonadotropin (hCG). This hormone is made right after a fertilized egg attaches
to the wall of a woman's uterus. This usually happens -- but not always -- about 6 days
after fertilization. If you're pregnant, levels of hCG continue to rise rapidly, doubling
every 2 to 3 days.
Blood typing- a test that determines a persons blood type. The test is essential if you
need a blood transfusion or are planning to donate blood. Not all blood types are
compatible, so its important to know your blood group. Receiving blood thats
incompatible with your blood type could trigger a dangerous immune response.
Blood transfusion- the transfer of blood or blood products from one person (donor) into
another person's bloodstream (recipient). This is usually done as a lifesaving maneuver to
replace blood cells or blood products lost through severe bleeding, during surgery when
blood loss occurs or to increase the blood count in an anemic patient.

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 LABORATORY RESULTS

HEMATOLOGY

TEST NAME RESULTS NORMAL VALUES SIGNIFICANCE

WBC (White Blood 5.45 5-10x10^9/L
Cells) This can result from bacterial
Neutrophils 62 0.55-0.65 infections, inflammation, and
Lymphocyte 27 0.25-0.40 leukemia.
Monocyte 11 0.02-0.06
M: 135-160 g/L Decreased in all anemias and
HGB (Hemoglobin) 34
F: 120-150g/L after hemorrhage.
Decreased in all various anemia
M: 5.5-6.0x10^12/L
RBC (Red blood cells) 2.43 and severe or prolong
F: 4.5-5.5 x10^12/L
hemorrhage.
PLT (Platelet) 411 190-440x10^12/L Within the Normal Range.
M: 0.40-0.48 HCT on PCV decrease, are an
Hematocrit 0.16
F: 0.37-0.45 indication of anemia.

Blood Type: O

ULTRASOUND

- Prominent spleen

- Normal size kidneys w/ diffuse parenchymal disease, likely due to pyelonephritic oranges

- Slightly enlarged uterus with suspicious masses and endometrial cavity and lower uterine
segment. Suggest TVS for better evaluation. Smaller nodule in fundal myometrium, consistent
w/ intramural myoma.

- Diffuse liver parenchymal disease, suggestive of schistosomiasis

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 HUMAN ANATOMY AND PHYSIOLOGY
(FEMALE REPRODUCTIVE SYSTEM)

The reproductive role of a female is much more complex than that of the male. Not only
must she produce the female gametes (ova), but her body must also nurture and protect a
developing fetus during nine months of pregnancy.

Functions are:
Produces eggs (ova).
Secretes sex hormones.
Receives the male spermatazoa during sexual intercourse.
Protects and nourishes the fertilized egg until it is fully developed.
Delivers fetus through birth canal.
Provides nourishment to the baby through milk secreted by mammary glands in the
breast.

Anatomy (External Female Organ)

Physiology (External Female Organ)

Mons Pubis a.k.a. Mons Veneris that protects the pubic bone and vulva from the impact
of sexual intercourse. After puberty, it is covered by pubic hair (responsible for not easily
harboring the microorganisms in the vagina.
Prepuce of Clitoris protective cover of glans of clitoris.
Glans of Clitoris a short erectile organ above the vagina that is responsible for sexual
excitation or pleasure.
Vestibule the gland at the point where vagina and vulva join that secretes lubricating
substance. It consists of 3 parts:
o Urethral Opening a.k.a. Meatus that drains urine from the bladder.
o Clitoris functions sexual pleasures.

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 o Vestibule of Vagina a.k.a. Vaginal Introitus that is for the vaginal entrance.
Openings of Paraurethral connected to the urethra and lubrication.
Labium a fleshy and liplike structure folds that protect the openings from bacterial
invasion. It has:
o Labia Majora elongated hair covered skin folds that are responsible for lubrication.
o Labia Minora smaller folds enclosed by the labia majora and their function is to protect
the vagina and urethra openings. And they also produce lubricant.
Vagina receives penis and semen during mating, and passageway of childbirth and
menstrual flow.
Hymenal Caruncle a.k.a. Hymen, a membrane which partially covers the vaginal
passage.
Opening of Greater Vestibular Gland a.k.a. Bartholins Glands, the two glands at the
side of the vagina and between the vulva that secretes a lubricating substance.
Vestibular Fossa a.k.a. Navicular Fossa, a small cavity of between the vaginal orifice
and fourchette.
Frenulum of Labium the fold connecting the two labia minora posteriorly.
Posterior Labia Commissure rear joining of the labia majora above the perineum.
Perineal Raphe ridge along the median line that runs forward from the anus.
Anus a.k.a. Anal Orifice, in which feces passes through.

Anatomy (Internal Female Organ)

Physiology (Internal Female Organ)

Ovaries paired shape of almonds. It produces ova (singular, ovum), or eggs. The two
ovaries present in each female are held in place by the following ligaments:
o Broad Ligament is a section of the peritoneum that drapes over the ovaries, uterus,
ovarian ligament, and suspensory ligament. It includes both the mesovarium and
mesometrium. The mesovarium is a fold of peritoneum that holds the ovary in place.

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 o Suspensory Ligament anchors the upper region of the ovary to the pelvic wall. Attached
to this ligament are blood vessels and nerves, which enter the ovary at the hilus.
o Ovarian Ligament anchors the lower end of the ovary to the uterus.
The following two tissues that cover the outside of the ovary:
o Germinal Epithelium is an outer layer of simple epithelium.
o Tunica Albuginea is a fibrous layer inside the germinal epithelium.
The inside of the ovary, or stroma, is divided into two indistinct regions:
o Outer Cortex and the Inner Medulla embedded in the cortex are saclike bodies called
ovarian follicles. Each ovarian follicle consists of an immature oocyte (egg) surrounded
by one or more layers of cells that nourish the oocyte as it matures.
o Follicular Cells the surrounding cells if they make up a single layer, or granulosa cells,
if more than one layer is present.
Uterine tubes (oviducts) transport the secondary oocytes away from the ovary and
toward the uterus (the ovaries consist of primary oocytes, which develop into secondary
oocytes). The following regions characterize each of the two uterine tubes (one for each
ovary):
Infundibulum is a funnel-shaped region of the uterine tube that bears fingerlike
projections called fimbriae. Pulsating cilia on the fimbriae draw the secondary oocyte
into the uterine tube.
o Ampulla is the widest and longest region of the uterine tube. Fertilization of the oocyte
by a sperm usually occurs here.
o Isthmus is a narrow region of the uterine tube whose terminus enters the uterus.
Wall of the Uterine Tube consists of the following three layers:
o Serosa a serous membrane, lines the outside of the uterine tube.
o Middle Muscularis consists of two layers of smooth muscle that generate peristaltic
contractions that help propel the oocyte forward.
o Inner Mucosa consists of ciliated columnar epithelial cells that help propel the oocyte
forward, and secretory cells that lubricate the tube and nourish the oocyte.
Uterus a hollow and pear-shaped organ that is to house, nourish and expel the fetus
during delivery; and for menstrual flow. It composes 3:
o Body or Corpus the main body part of the uterus.
o Fundus superior rounded region above the entrance of the uterine tubes.
o Isthmus slightly constricted portion that joins the corpus to the cervix.
Uterus is held in place by the following ligaments:
o Broad ligaments - fold of peritoneum supporting the uterus, extending from the uterus to
the wall of the pelvis on either side.
o Utero-sacral ligaments - a part of the thickening of the visceral pelvic fascia beside the
cervix and vagina; called also Petit's Ligament.
o Round ligaments - a fibromuscular band attached to the uterus near the uterine tube,
passing through the inguinal ring to the labium majus.

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 o Cardinal (lateral cervical) ligaments - part of a thickening of the visceral pelvic fascia
beside the cervix and vagina, passing laterally to merge with the upper fascia of the
pelvic diaphragm.
Wall of the Uterus consists of the following three layers:
o Perimetrium is a serous membrane that lines the outside of the uterus.
o Myometrium consists of several layers of smooth muscle and imparts the bulk of the
uterine wall. Contractions of these muscles during childbirth help force the fetus out of
the uterus.
o Endometrium is the highly vascularized mucosa that lines the inside of the uterus. If an
oocyte has been fertilized by a sperm, the zygote (the fertilized egg) implants on this
tissue.
Endometrium itself consists of two layers:
o Stratum Functionalis (functional layer) is the innermost layer (facing the uterine lumen)
and is shed during menstruation.
o Stratum Basalis (basal layer) is permanent and generates each new stratum functionalis.
o Vagina (birth canal) serves both as the passageway for a newborn infant and as a
depository for semen during sexual intercourse. It consists of the following layers:
o Outer Adventitia holds the vagina in position.
o Middle Muscularis consists of two layers of smooth muscle that permit expansion of
the vagina during childbirth and when the penis is inserted.
o Inner Mucosa has no glands. But bacterial action on glycogen stored in these cells
produces an acid solution that lubricates the vagina and protects it against microbial
infection. The acidic environment is also inhospitable to sperm. The mucosa bears
transverse ridges called rugae.

Anatomy (Female Internal Cervix)

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Physiology (Female Internal Cervix)

Cervix is the 3rd lower portion of the uterus, neck like part (uteri cervix), narrowed
where it joins of the top end of the vagina. Cylindrical in shape and protrudes through the upper
anterior vaginal wall.
It has cervical mucus that is made of 90% of water, depending on the water content which
varies during the menstrual cycle that functions as barrier. It usually contains electrolytes, mainly
Calcium, Sodium, and Potassium, organic components such as amino acids and soluble proteins.
It is also composed of zinc, copper, iron, manganese, and selenium elements.
After menstrual period, the external os is blocked by mucus that is thick and acidic and it
undergoes a series of changes in position and texture of cervix uteri and wall.

Hormonal Regulation of Oogenesis and Menstrual Cycle

Three estrogens circulate in the bloodstream: (1) estradiol, (2) estrone, and (3) estriol. All have
similar effects on their target tissues. Estradiol is the most abundant estrogen, and its effects on
target tissues are most pronounced. It is the dominant hormone prior to ovulation. In estradiol
synthesis, androstenedione is first converted to testosterone, which the enzyme aromatase
converts to estradiol. The synthesis of both estrone and estriol proceeds directly from
androstenedione.
Estrogens have multiple functions that affect the activities of many tissues and organs throughout
the body. Among the important general functions of estrogens are (1) stimulating bone and
muscle growth, (2) maintaining female secondary sex characteristics, such as body hair
distribution and the location of adipose tissue deposits, (3) affecting central nervous system
(CNS) activity (especially in the hypothalamus, where estrogens increase the sexual drive), (4)
maintaining functional accessory reproductive glands and organs, and (5) initiating the repair and
growth of the endometrium.

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Ovarian Cycle Events Uterine Cycle Events
Follicular phase - Menstruation - Days
FSH secretion begins. Endometrium breaks down.
Days 1-13 2-5
Follicle maturation Proliferative phase -
Endometrium rebuilds.
occurs. Days 6-13
Estrogen secretion is
prominent.
Ovulation - Day
LH spike occurs.
14*
Luteal phase - Secretory phase - Endometrial thickens, and
LH secretion continues.
Days 15-28 Days 15-28 glands are secretory.
Corpus luteum forms.
Progesterone secretion
is prominent.
The purpose of these cycles is to produce an egg and to prepare the uterus for the implantation of
the egg, should it become fertilized. The ovarian cycle consists of three phases:

1. Follicular Phase describes the development of the follicle, the meiotic stages of division
leading to the formation of the secondary oocytes, and the secretion of estrogen from the follicle.

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2. Ovulation, Occurring at midcycle is the ejection of the egg from the ovary.

3. Luteal Phase describes the secretion of estrogen and progesterone from the corps
luteum (previously the follicle) after ovulation.

The menstrual (uterine) cycle consists of three phases:

1. Proliferative phase describes the thickening of the endometrium of the uterus, replacing
tissues that were lost during the previous menstrual cycle.

2. Secretory phase - follows ovulation and describes further thickening and vascularization
of the endometrium in preparation for the implantation of a fertilized egg.

3. Menstrual phase (menstruation, menses) describes the shedding of the endometrium

when implantation does not occur.

The activities of the ovary and the uterus are coordinated by negative- and positive-feedback
responses involving gonadotropin releasing hormone (GnRH) from the hypothalamus, follicle
stimulating hormone (FSH) and luteinizing hormone (LH) from the anterior pituitary, and the
hormones estrogen and progesterone from the follicle and corpus luteum. A description of the
events follows):

1. Hypothalamus and anterior pituitary initiate the reproductive cycle: The hypothalamus
monitors the levels of estrogen and progesterone in the blood. In a negative-feedback fashion,
low levels of these hormones stimulate the hypothalamus to secrete GnRH, which in turn
stimulates the anterior pituitary to secrete FSH and LH.

2. Follicle develops: FSH stimulates the development of the follicle from primary through
mature stages.

3. Follicle secretes estrogen: LH stimulates the cells of the theca interna and the granulosa
cells of the follicle to secrete estrogen. Inhibin is also secreted by the granulosa cells.

4. Ovulation occurs: Positive feedback from rising levels of estrogen stimulate the anterior
pituitary (through GnRH from the hypothalamus) to produce a sudden midcycle surge of LH.
This high level of LH stimulates meiosis in the primary oocyte to progress toward prophase II
and triggers ovulation.

5. Corpus luteum secretes estrogen and progesterone: After ovulation, the follicle, now
transformed into the corpus luteum, continues to develop under the influence of LH and secretes
both estrogen and progesterone.

6. Endometrium thickens: Estrogen and progesterone stimulate the development of the

endometrium, the inside lining of the uterus. It thickens with nutrient-rich tissue and blood
vessels in preparation for the implantation of a fertilized egg.

7. Hypothalamus and anterior pituitary terminate the reproductive cycle: Negative feedback
from the high levels of estrogen and progesterone cause the anterior pituitary (through the
hypothalamus) to abate the production of FSH and LH. Inhibin also suppresses production of
FSH and LH.

8. Endometrium either disintegrates or is maintained, depending on whether implantation of

the fertilized egg occurs, as follows:

o Implantation does not occur: In the absence of FSH and LH, the corpus luteum
deteriorates. As a result, estrogen and progesterone production stops. Without estrogen and
progesterone, growth of the endometrium is no longer supported, and it disintegrates, sloughing
off during menstruation.

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o Implantation occurs: The implanted embryo secretes human chorionic gonadotropin
(hCG) to sustain the corpus luteum. The corpus luteum continues to produce estrogen and
progesterone, maintaining the endometrium. (Pregnancy tests check for the presence of hCG in
the urine).

Menopause is the cessation of menstruation. This usually occurs in women between the
ages of 45 and 50. Some women may reach menopause before the age of 45 and some after the
age of 50. In common use, menopause generally means cessation of regular menstruation.
Ovulation may occur sporadically or may cease abruptly. Periods may end suddenly, may
become scanty or irregular, or may be intermittently heavy before ceasing altogether. Markedly
diminished ovarian activity, that is, significantly decreased estrogen production and cessation of
ovulation, causes menopause.

PATHOPHYSIOLOGY
(NARRATIVE FORM)

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 Cancer of the cervix typically originates from a dysplastic or premalignant lesion
previously present at the active squamous columnar junction. The transformation from mild
dysplastic to invasive carcinoma generally occurs slowly within several years, although the rate
of this process varies widely.
Carcinoma in situ is particularly known to precede invasive cervical cancer in most cases.
In different reported series of patients with untreated carcinoma in situ who were followed up for
many years, invasive carcinoma developed in about 30% of patients at 10 years and in about
80% of patients at 30 years. However, the carcinoma-in-situ lesion may regress after the initial
diagnosis; such an occurrence was reported in 17 (25%) of 67 patients who were followed up for
at least 3 years. Progression to invasive carcinoma becomes established and is considered
irreversible once the malignant process extends through the basement membrane and invasion of
the cervical stroma occurs.
Multiple local growth patterns of invasive cervical cancer have been described, with
combination growth patterns being common. The patterns include the following: exophytic,
nodular, infiltrative, and ulcerative.
The exophytic variety is the most common growth pattern. It usually arises from the exocervix
and is often polypoid or papillary in form. Exophytic cervical cancer may result in a large,
friable, bulky mass that involves only the superficial aspect of the cervix and has the tendency
for excessive bleeding.
The nodular variety typically arises in the endocervix and grows through the cervical
stroma into confluent, firm masses that cause the cervix and isthmus to expand. Large, nodular-
type tumors that circumferentially involve the endocervical region and large, exophytic-type
tumors that originate from the endocervix and extend into the endocervical canal result in what
has been referred to as a barrel-shaped cervix.
The infiltrative growth pattern leads to a stone-hard cervix that may be predicated to have
minimal visible ulcerations or an exophytic mass. Infiltrative exocervical lesions tend to invade
the vaginal fornices and the upper part of the vagina. On the other hand, infiltrative endocervical
lesions tend to extend into the corpus and the lateral parametrium

21
 PATHOPHYSIOLOGY
(SCHEMATIC DIAGRAM)
PRECIPITATING FACTORS
PREDISPOSING FACTORS Sexual partner who had multiple sexual partner
Age (48 years old) (HPV exposure)
Sex (exclusively for female) Low economic status
Heredity (history of cervical CA) Diet and lifestyle

Somatic Mutation in DNA

or Gene

Activated oncogene or deactivate cell

tumor suppressor gene
Altered genetic structure and
autoimmune response

Formation of clones or uncontrolled proliferation

lymphocytes
Malignant transformation of lymphoid
stem cells

Cervix cells dysplasia after lymphoblastic cell event

22
Acquisition of invasive characteristics
 Tumor cells engulf lymphocytes

Altered production of normal cells

Virus transcripts stroma
Through sexual intercourse: HPV penetrates
squamous columnar epithelial cervix cells
Activation of oncogenic cell growth
factor
Hematology
Lab Result: Hematology
Increased Lab Result:
WBC 5.45 Decreased
RBC 2.43
10^12/L
Tumor cells attach in the cervix cells
S/Sx:
Infection
Fatigue
Pallor Host cells
Spread put up tissue
and invades barrier
distant tissues
Increased RR: 25cpm (vagina)

Autoimmune inhibition progression

(malignant)

Asymptomatic tumor growth

Diagnostic Test:
Cervical Biopsy

Affection of the surrounding tissues

of the cervix along the vagina

Cervical Cancer Stage III

23
 Necrosis and infection of the
tumor

S/Sx:
Treatment: Vaginal Bleeding
GainIrritation
access toof
pelvic
S/Sx:
Dark and Foul nervelymph nodes
endings Excruciating pain
tranexamic acid
Odor Increased tumor growth in back and legs

Fundus
Hypermetabolic activity

Hematology
Lab Result: Treatment:
Decreased Pressure on the surrounding analgesic
HGB 34 Weight loss: tissue
45 40 kl. of the
pt. weight.

PROGNOSIS

With Medical Management: Without Medical

Hysterectomy Management:
Chemotherapy Tumor Metastsis may
Radiation Therapy occur

Poor Prognosis

IVF Replacement Multi-organ failure or

Follow prescribed complication and Sepsis
medication by the
Good Prognosis
physician

24
 Possible for recovery Coma

35 40% Rate of Survival;

about 5 yrs. in Cervical CA
Stage III Death

LEGENDS:

RISK FACTORS PATHOLOGY MANAGEMENT/DIAGNOSTIC TEST

LABORATORY
MANIFESTATIONS TEST/RESULT

25
 DRUG STUDY #1

GENERIC NAME: Paracetamol

Brand name: Biogesic

Drug Classification: Analgesics

DOSAGE, ROUTE, MECHANISM OF SIDE EFFECTS and ADVERSE

FREQUENCY (prescribed INDICATION ACTION REACTIONS (by system)
and recommended)
Paracetamol has Paracetamol (acetam
Dosage Forms & Strengths Minimal GI upset.
good analgesic inophen) is generally
tablet and antipyretic considered to be a Methemoglobinemia
325mg properties. It is weak inhibitor of the
Hemolytic Anemia
500mg suitable for the synthesis of
caplet treatment of prostaglandins (PGs). Neutropenia
325mg pains of all kinds However, the in vivo Thrombocytopenia
500mg (headaches, effects
dental pain, of paracetamol are Pancytopenia
650mg
capsule postoperative similar to those of Leukopenia
500mg pain, pain in the selective
connection with cyclooxygenase-2 Urticaria
gelcap/geltab
colds, post- (COX-2) inhibitors. CNS stimulation
500mg
traumatic muscle
caplet, extended-release Hypoglycemic coma
pain).
650mg
tablet, chewable Jaundice
80mg Glissitis
tablet, oral-disintegrating
80mg Drowsiness
160mg Liver Damage
oral solution/suspension
160mg/5mL
80mg/0.8mL (oral
drops)
liquid oral
500mg/5mL
160mg/15mL
500mg/15mL
syrup oral
160mg5mL
elixir
160mg/5mL
Analgesia & Fever
immediate-release
Regular strength:
325-650 mg PO/PR
q4hr PRN; not to
exceed 3250 mg/day;
under supervision of

26
 healthcare
professional, daily
doses of up to 4
g/day may be used
Extra Strength:
1000 mg PO q6-8hr
PRN; not to exceed
3000 mg/day; under
supervision of
healthcare
professional, daily
doses of up to 4
g/day may be used

CONTRAINDICATION/S NURSING RESPONSIBILITIES (at least 10)

1. Renal Insufficiency 1. Do not exceed 4gm/24hr. in adults and
2. Anemia 75mg/kg/day in children.
2. Do not take for >5days for pain in children, 10
days for pain in adults, or more than 3 days for
fever in adults.
3. Extended-Release tablets are not to be chewed.
4. Monitor CBC, liver and renal functions.
5. Assess for fecal occult blood and nephritis.
6. Avoid using OTC drugs with Acetaminophen.
7. Take with food or milk to minimize GI upset.
8. Report N&V. cyanosis, shortness of breath and
abdominal pain as these are signs of toxicity.
9. Report paleness, weakness and heart beat skips
10. Report abdominal pain, jaundice, dark urine,
itchiness or clay-colored stools.
11. Phenmacetin may cause urine to become dark
brown or wine-colored.
12. Report pain that persists for more than 3-5 days
13. Avoid alcohol.
14. This drug is not for regular use with any form of
liver disease.

27
 DRUG STUDY #2

GENERIC NAME: Tramadol

Brand name: Ultram, Ultram ER, ConZip

Drug Classification: Opioid Analgesics

DOSAGE, ROUTE, FREQUENCY
(prescribed and recommended) INDICATION MECHANISM OF SIDE EFFECTS and
ACTION ADVERSE REACTIONS (by
system)
Tramadol (+/-)-Tramadol is a headache,
Dosage Forms & Strengths hydrochloride is selective agonist of mu dizziness, drowsiness,
tablet: Schedule IV indicated for the receptors and tired feeling; constipation,
50mg management of preferentially inhibits diarrhea, nausea,
suspension reconstituted moderate to serotonin reuptake, vomiting, stomach pain;
10 mg/mL moderately severe whereas (-)- feeling nervous or
capsule, extended release: Schedule pain in adults. tramadol mainly anxious; or itching,
IV inhibits noradrenaline sweating, flushing
100mg (ConZip, Ultram ER) reuptake. The action of (warmth, redness, or
150mg (ConZip) these 2 enantiomers is tingly feeling).
200mg (ConZip, Ultram ER) both complementary
300mg (ConZip, Ultram ER) and synergistic and
results in the analgesic
Moderate-to-Severe Pain effect of (+/-)-
tramadol.
Immediate release
Chronic: 25 mg PO every
morning initially; increased by
25-50 mg/day every 3 days up
to 50-100 mg PO q4-6hr PRN;
not to exceed 400 mg/day
Acute: 50-100 mg PO q4-6hr
PRN; not to exceed 400
mg/day
Extended release
100 mg PO once daily
initially; increased by 100
mg/day every 5 days; not to
exceed 300 mg/day
Conversion from immediate
release to extended release:
Round total daily dose down
to nearest 100 mg
Do not chew, crush, split, or
dissolve

28
 CONTRAINDICATION/S
Tramadol 50mg/ml Solution for injection should not be
given to patients suffering from acute intoxication with
alcohol, hypnotics, centrally acting analgesics, opioids
orpsychotropic drugs.
29
NURSING RESPONSIBILITIES (at least 10)
Assess for level of pain relief and
administer prn dose as needed but
not to exceed the recommended
total daily dose.
Monitor vital signs and assess for
orthostatic hypotension or signs of
CNS depression.
Discontinue drug and notify physician
if S&S of hypersensitivity occur.
Assess bowel and bladder function;
report urinary frequency or
retention.
Use seizure precautions for patients
who have a history of seizures or
who are concurrently using drugs
that lower the seizure threshold.
Monitor ambulation and take
appropriate safety precautions.
Control environment (temperature,
lighting) if sweating or CNS effects
occur.
WARNING: Limit use in patients with
past or present history of addiction
to or dependence on opioids.
 DRUG STUDY #3

GENERIC NAME: Tranexamic Acid

Brand name: Hemostan, Fibrinon, Cyklokapron, Lysteda, Transamin

Drug Classification: Anti-fibrinolytic, antihemorrhagic

DOSAGE, ROUTE, MECHANISM OF SIDE EFFECTS and

FREQUENCY INDICATION
(prescribed and
recommended)
Dosage Forms & Tranexamic acid is used
Strengths for the prompt and
effective control of
Tablet- 650mg hemorrhage in various
surgical and clinical
Menorrhagia
areas:
1300 mg PO TID for up to Treating heavy
5 days during menstrual bleeding
menstruation Hemorrhage
following dental
Renal impairment
and/or oral surgery
in patients with
SCr >1.4 mg/dL
hemophilia
and 2.8 mg/dL:
Management of
1300 mg PO BID
hemophilic patients
SCr >2.8 mg/dL (those having Factor
and 5.7 mg/dL:
VIII or Factor IX
1300 mg PO qDay
deficiency) who
have oral mucosal
SCr >5.7 mg/dL:
bleeding, or are
650 mg PO qDay
undergoing tooth
extraction or other
Each regimen
listed above may oral surgical
procedures.
be administered
for up to 5 days Surgical: General
during surgical cases but
menstruation most especially
operative
Hereditary procedures on the
Angioedema (Off-
ACTION
Tranexamic acid is a
synthetic derivative of
the amino acid lysine. It
exerts its antifibrinolytic
effect through the
reversible blockade of
lysine-binding sites on
plasminogen molecules.
Anti-fibrinolytic drug
inhibits endometrial
plasminogen activator
and thus prevents
fibrinolysis and the
breakdown of blood
clots. The plasminogen-
plasmin enzyme system is
known to cause
coagulation defects
through lytic activity on
fibrinogen, fibrin and
other clotting factors. By
inhibiting the action of
plasmin (finronolysin) the
anti-fibrinolytic agents
reduce excessive
breakdown of fibrin and
effect physiological
hemostasis.
ADVERSE REACTIONS
(by system)
Severe allergic
reactions such as
rash, hives, itching,
dyspnea, tightness in
the chest, swelling of
the mouth, face, lips
or tongue
Calf pain, swelling or
tenderness
Chest pain
Confusion
Coughing up blood
Decreased urination
Severe or persistent
headache
Severe or persistent
body malaise
Shortness of breath
Slurred speech
Slurred speech
Vision changes

30
label) prostate, uterus,
thyroid, lungs,
Long term prophylaxis: heart, ovaries,
1000-1500 mg PO q8- adrenals, kidneys,
12hr; reduce dose to 500 brain, tonsils, lymph
mg/dose PO qDay or nodes and soft
q12hr when frequency of tissues.
attacks reduces Obstetrical and
Short term prophylaxis: gynecological:
75 mg/kg/day PO divided abortion, post-
q8-12hr for 5 days before partum
and after the event hemorrhage and
menometrorrahgia
Treatment of acute HAE Medical: epistaxis,
attack: 25 mg/kg/dose hemoptysis,
PO/IV; not to exceed hematuria, peptic
1000 mg/dose q3-4hr; ulcer with
not to exceed 75 hemorrhage and
mg/kg/day or 1000 mg blood dyscrasias
PO q6hr for 48 hr with hemorrhage
Cone Biopsy (Off- Effective in
label) promoting
hemostasis in
1000-1500 mg q8-12hr traumatic injuries.
x12 days postop Preventing
hemorrhage after
Epistaxis (Off-
orthopedic
label)
surgeries.
1000-1500 mg q8-12hr
x10 days

Hyphema (Off-
label)

1000-1500 mg q8-12hr x7
days

Hereditary
Angioedema (Off-
label)

1000-1500 mg PO
BID/TID

Administration

May take with or without

food

Swallow whole, do not

31
chew, break, or crush
CONTRAINDICATION/S
1. Allergic reaction to the drug or hypersensitivity
2. Presence of blood clots (eg, in the leg, lung, eye,
brain), have a history of blood clots, or are at risk
for blood clots
3. Current administration of factor IX complex
concentrates or anti-inhibitor coagulant
concentrates
Precautions
1. Pregnancy. Tranexamic acid crosses the
placenta.
2. Lactation. Tranexamic acid is distributed into
breast milk; concentrations reach
approximately 1% of the maternal plasma
concentration.
3. Contraceptives, estrogen-containing, oral or
Estrogens. Concurrent use with tranexamic
acid may increase the potential for thrombus
formation.
4. Renal function impairment (medication may
accumulate; dosage adjustment based on the
degree of impairment is recommended)
5. Hematuria of upper urinary tract origin (risk
of intrarenal obstruction secondary to clot
retention in the renal pelvis and ureters if
hematuria is massive; also, if hematuria is
associated with a disease of the renal
parenchyma, intravascular precipitation of
fibrin may occur and exacerbate the disease).
32
NURSING RESPONSIBILITIES (at least 10)
1. Unusual change in bleeding pattern should be
immediately reported to the physician.
2. For women who are taking Tranexamic acid to
control heavy bleeding, the medication
should only be taken during the menstrual
period.
3. Tranexamic Acid should be used with extreme
caution in CHILDREN younger than 18 years
old; safety and effectiveness in these children
have not been confirmed.
4. The medication can be taken with or without
meals.
5. Swallow Tranexamic Acid whole with plenty
of liquids. Do not break, crush, or chew
before swallowing.
6. If you miss a dose of Tranexamic Acid, take it
when you remember, then take your next
dose at least 6 hours later. Do not take 2
doses at once.
7. Inform the client that he/she should inform
the physician immediately if the following
severe side effects occur:
 PRIORITY NURSING DIAGNOSIS #1
Imbalanced Nutrition: Less than Body Requirements

CUES/EVIDENCES

Subjective

"Gamay ra jud akong kinan.an pirme" as verbalized by the patient.

Objective

- Weight loss
- Thin
- Poor muscle tone
- Lack of interest in food
- Weight: 41 kg
- V/S as follows:
o T 36.4
o P 118
o R 20
o BP 110/60

GOAL
Short-Term Goal

After 4 hours of holistic nursing interventions, the patient will verbalize understanding of
causative factors and necessary interventions to promote optimum nutrition.

33
Long-Term Goal

After 2 days of holistic nursing interventions, the patient will be able to demonstrate behavior
and lifestyle changes to regain appropriate weight.

INTERVENTION/RATIONALE

Ascertain patients understanding of individual nutritional needs.

- To determine informational needs of client

Assess weight, measure, or calculate body fat.

- To establish baseline parameter

Assess patients ability to chew, swallow, and taste food.

- To determine factors that can affect ingestion and digestion of nutrients.

Discuss eating habits including food preferences, intolerance, and aversion.

- To appeal to patient tasks and enhance intake

Encourage patient to choose food or have family member to bring food that seems
appealing.
- To stimulate the appetite of the patient

Instruct client to avoid foods that causes intolerance or increase gastric motility according
to individual needs. Limit fiber or bulk, if indicated.
- Because it may lead to early satiety

Weigh at regular intervals and document results.

- To monitor effectiveness of dietary plan

34
 Consult with dietician and nutritional support team as necessary.
- To have an accurate dietary intake for long-term needs

Refer to home-health resources.

- For initiation and supervision of hoke nutrition therapy when used

35
 PRIORITY NURSING DIAGNOSIS #2
Ineffective Tissue Perfusion

CUES/EVIDENCES

Subjective

Anemic man gud ko as verbalized by the patient.

Objective

- Low Hemoglobin level: 34 g/L (normal: 120-150 g/L)

- Low Hematocrit level: 0.16 (normal: 0.37-0.45)
- Pale palpebral conjunctiva
- V/S as follows:
o T 36.4
o P 118
o R 20
o BP 110/60

GOAL
Short-Term Goal

After 2 hours of holistic nursing interventions, the patient will be able to verbalize understanding
of condition and enumerate pharmacologic and non-pharmacologic regimen.

36
Long-Term Goal

After 2 days of holistic nursing interventions, the patient will demonstrate increased perfusion
with manifestation of normal vital signs.

INTERVENTION/RATIONALE

Monitor vital signs.

- To have a baseline data and note any abnormal findings

Measure intake and output on a regular basis.

- To monitor patients hydration

Caution to avoid activities that increase the hearts workload.

- Activities that requires too much workload leads to heart stress

Encourage ambulation as often as possible.

- To promote venous return

Instruct patient to elevate legs.

- To promote venous return

Promote adequate fluid intake.

- To prevent stasis of body fluids

Advise patient to eat iron-rich foods.

- For blood production

Administer medications as needed.

- To improve tissue perfusion

37
 Administer IV fluids as ordered.
- To maintain circulating volume to maximize tissue perfusion

Blood component therapy (blood transfusion) as ordered.

- Blood transfusion increases the patients blood volume

Review specific dietary changes with the patient.

- Specific nutrients are needed to meet the needs of the patient

38
 PRIORITY NURSING DIAGNOSIS #3
Risk for Infection

CUES/EVIDENCES

Subjective
Gidugo man gud ko tas baho kaayo siya tas lasaw, isa nani kabulan," as verbalized by the
patient

Objective
constantly using of diapers for atleast 1 month
2-3 diapers consumed for each day
V/S:
Blood pressure: 110/60
Heart rate: 118
Temperature:36.4
Respiratory Rate:20

GOAL
Short-Term Goal
After 8 hours of duty the patient will be able to understand the cause of her illness

Long-Term Goal
After 16 hours of duty the patient will be able to apply several intervention to prevent/reduce risk
of infection.

39
INTERVENTION/RATIONALE

Stress the importance of proper hand hygiene to the patient.

- to reduce the risk of cross-contamination
Instruct patient not to use diapers or sanitary napkin for too long.
- to avoid the pathogenic organisms being invaded in our body
Teach patient on how to clean perineal are
- in order for the patient to be aware and apply it to her self for infection control
Administer/monitor medication regimen and note clients response
- to determine effectiveness of therapy/presence of side effects
Emphasize necessity of taking antivirals/antibiotics, as directed
- premature discontinuation of treatment when client begins to feel well may result in
return of infection and potentiate drug-resistant strains.
Promote safer-sex practices and report sexual contacts of infected individual
- to prevent the spread of HIV/other sexually transmitted disease
Provide information/involve in appropriate community and national education programs
- to increase awarness of and prevention of communicable disease
Recommend routine or preoperative body shower/scrubs when indicated.
- to reduce bacterial colonization

40