University of Makati College of Allied Health Studies J.P.

Rizal Extension West Rembo, Makati City

BASAL CELL CARCINOMA

A Case Study Presented to Prof. Olympia Perez ,RN,MAN Instructor, College of Allied Health Studies, AY 2011-2012

Presented by: Alsol, Lawrenz H. Bathan, Erika M. Benavides, Rogienette A. Coronado, Jordan O. Elocre, Honey Grace Garrido, Czarina R.

February 1, 2012

I. INTRODUCTION Skin cancer is the most common form of human cancer. It is estimated that over 1 million new cases occur annually. The annual rates of all forms of skin cancer are increasing each year, representing a growing public concern. The term "skin cancer" refers to three different conditions. From the least to the most dangerous and they are Basal cell carcinoma or also known as Basal cell carcinoma epithelioma, squamous cell carcinoma and melanoma. Among the three stated conditions of skin cancer Basal cell carcinoma is the most common form of skin cancer and accounts for more than 90% of all skin cancer in the U.S. These cancers almost never spread or metastasize to other parts of the body. However, it could cause damage by growing and invading the surrounding tissue. Basal cell carcinoma occurs when one of the skin's basal cells develops a mutation in its DNA. Basal cells are found at the bottom of the epidermis which produces new skin cells. As new skin cells are produced, they push older cells toward the skin's surface, where the old cells die and are sloughed off. Factors that may increase risk of having this type of cancer includes chronic sun and radiation exposure, fair skin, being male, personal or family history of skin cancer and taking of immuno-suppressants. The patient may have skin sore that bleeds easily and does not heal, he may also have an oozing or crusting spots in a sore and a sore with a depressed or sunken area in the middle.

Preventions that may be done to reduce risk of having this type of cancer are avoiding exposing the skin during midday sun which is between 10 am and 4pm. Using of sunscreen lotion is also advisable because it blocks both UVA and UVB. Since the sunscreen does not completely provide protection from UV rays, wearing of protective clothing will be a great help in prevention of acquiring cancer. Clothing that is tightly woven that covers arms and legs to provide more protection. There are numbers of treatment and drugs that are now use to combat skin cancer. Treatment that is the best for you will still depend on type, location and severity of the cancer. Some of the most commonly used treatments include Electrodesiccation and curettage, Surgical excision, Freezing, Mohs surgery, and Topical treatments. In 2002, 4.2 million new cancer cases, which accounted to 39% of new cases worldwide, were diagnosed among 3.2 billion persons (48% of the world population) living in the fifteen most highly developed countries in South, East, and Southeast Asia which are the following: Japan, Taiwan, Singapore, South Korea, Malaysia, Thailand, China, Philippines, Sri Lanka, Vietnam, Indonesia, Mongolia, India, Laos, and Cambodia. China and India, together accounting for 37% of the worldwide population, reported 3 million of these newly diagnosed cancer cases.

II. BIOGRAPHICAL DATA Name: Patient X Age: 76 years old Gender: Female Status: Widow Address: Cembo, Makati City Date of Birth: May 15, 1935 Place of Birth: Leyte Nationality: Filipino Religion: Roman Catholic Date of Admission: November 22, 2011 Time of Admission: 8:01 am Name of Informant: Perla Cabrigo Relation to Patient: Niece Reliability: 85%

III. HISTORY OF PRESENT ILLNESS Seven years prior to admission the client encountered vehicular accident which lead to the trauma to the forehead. The client rushed to the hospital after a long hours of bleeding of the wound. Client admitted to the Ospital ng Makati, Acute Care Center (ACC). The bleeding was managed but was not able to acquire medications after the discharge of the client. As alternative management to the wound, the client was applying herbal medicines which are sili, malunggay and luya. Six years prior to admission the client experienced signs and symptoms such as inflammation to the site and irritation of the eye which is affected. The client seek for a medical attention so she was admitted to the Hospital in Cubao, Quezon City. The client undergone to biopsy which is to examine her forehead. Again, the client was not able to have a medications. The client still continue the use of herbal medicines for her forehead. Five years prior to admission the client was admitted to the Ospital ng Makati. The clients signs and symptoms were managed and was discharged with an eye oinment. The client was adviced to go to the Out-Patient Department (OPD) when the signs and symptoms persisted. Two years prior to admission the client was referred to the Philippine General Hospital, Manila to undergone to Biopsy. One month prior to admission the client was admitted to the surgery department, Ospital ng Makati. The client was admitted to undergo specific surgical produre. Past Medical History

IV. REVIEW OF SYSTEMS (+) weight loss (-) headache (-) cough (-) abdominal pain (-) palpitations (-) syncope (-) constipation (-) frequency (-) nocturia (-) dizziness (-) fever (-) orthopnea (-) haemoptysis (-) urgency (-) rash (-) dysphagia (-) night sweats (-) vomiting (+) easy bruisability (-) chest pain (-) cyanosis (-) diarrhea (-) claudication (-) dyspnoea (-) dysuria (-) oliguria (-) seizures (-) polyphagia

(-) easy fatigability (-) bipedal edema (-) nausea (-) melena (-) anorexia (-) hematuria (-) polydipsia (-) PNDs (-) hematochezia (-) anuria (-) flank pain (-) polyuria

V. FAMILY HISTORY The patient have history of (-) Hypertension, (-) Measles, (-) PTB, (-) Asthma in their family. There are also no history of heart diseases and cancer that the patient reported.

VI. PAST MEDICAL HISTORY The client has been admitted in the hospital on the year 1950 to undergone to appendectomy. The client was also admitted to hospital and has been diagnosed as Pulmonary Tuberculosis on the 1997 the signs and symptoms are managed and treated accordingly.

VII. PHYSICAL ASSESSMENT Head Generally round, with prominences in the frontal and occipital area. No tenderness noted upon palpation. Eyes Upper eyelids cover the small portion of the iris, cornea, and sclera when eyes are open.
No PTOSIS noted. (Drooping of upper eyelids).

Meets completely when eyes are closed. Symmetrical. Nose Nose in the midline No Discharges.

Both nares are patent.

No bone and cartilage deviation noted on palpation No tenderness noted on palpation. Nasal septum in the mid line and not perforated. The nasal mucosa is pinkish to red in color. (Increased redness turbinates are typical of allergy). No tenderness noted on palpation of the paranasal sinuses. Ears The ear lobes are bean shaped, parallel, and symmetrical. The upper connection of the ear lobe is parallel with the outer canthus of the eye Skin is same in color as in the complexion. No lesions noted on inspection. The auricles are has a firm cartilage on palpation. The pinna recoils when folded. There is no pain or tenderness on the palpation of the auricles and mastoid process.
The ear canal has normally some serumen of inspection.

No discharges or lesions noted at the ear canal.

Neck The neck is straight. No visible mass or lumps. Symmetrical No jugular venous distension Skin Dry skin No lesions Nail Pink nail beds Abdomen Skin color is uniform, no lesions. No mass palpated Extremities Both extremities are equal in size. Have the same contour with prominences of joints No edema

VIII. ANATOMY AND PHYSIOLOGY

EPIDERMIS
o o o

The superficial layer that makes up the surface of the skin It is composed of skin cells and can be divided into 5 layers based on cell type. The top layer of the epidermis, the stratum corneum, is made of dead, flat skin

cells that shed about every 2 weeks.

o

The thickness of the epidermis varies, according to location: it is very thick over

the soles of the feet, and very thin over the ears. DER

DEDERMIS
o

Lies beneath the epidermis

o

Also varies in thickness depending on the location of the skin. It is .3 mm on the and 3.0 mm on the back. The dermis is composed of 2 layers that contain a connective tissue called

eyelid
o

collagen
o o o

The dermis contains blood vessels, nerves, sweat glands, and hair follicles. The number of structures in the dermis varies, according to location. The dermis under the arms contains more sweat glands and hair follicles than the

dermis on the back. SUBCUTANEOUS LAYER

o o

Mainly fat and connective tissue. Contains blood vessels and nerves.

IX. LABORATORY RESULTS CLINICAL CHEMISTRY SECTION TEST NAME Na K Cl RESULT 141 meq/L 4 105 NORMAL VALUES 136-145 3.5-5.1 98-107

HEMATOLOGY RESULTS 11.7 O.30 5.2 3.6 NORMAL VALUES 12-16 g/L 0.30-0.47 4-11x10/c 4.2-6.0

HEMOGLOBIN HEMATOCRIT WHITE BLOOD CELLS RED BLOOD CELLS DIFFERENTIAL COUNT EOSINOPHILS NEUTROPHILS

0.02

0.02-0.04

SEGMENTERS LYMPHOCYTES MONOCYTES

0.55 0.38 0.05

0.50-0.70 0.20-0.40 0.02-0.05 150-450x10/c 10.6-16.0 secs 73-127% 0.88-1.21 30.4-41.2

PLATELET COUNT 297 PTT 11.3secs 111.8 % 0.95 39.2

X. DIFFERENTIAL DIAGNOSIS

Patients Signs and Symptoms Pearly or Shinny (papulea) White or light pink Flesh-colored or brown

Squamous Cell Carcinoma

Basal Cell Carcinoma

Malignant Melanoma

A skin sore that bleeds easily A sore that does not heal Oozing or crusting spots in a sore Appearance of a scarlike sore without having injured the area Irregular blood vessels in or around the spot

A sore with a depressed (sunken) area in the middle

Weight loss Ulcerates then invades the underlying tissues

XI. PATHOPHYSIOLOGY
Modifiable factors UV ray exposure Non-Modifiable factors Genetics

Idiopathic

Basal Cell DNA Crosslinkage DNA point mutation Deactivation of DNA repair gene Proto Oncogene mutation to Oncogene Mutated Daughter cells fail to be developed as keratin Rapid Cell Division Deposition of mutated cells on the basal layer of epidermis Inactivated tumor suppressor gene Altered Mitosis

Formation of tumor Release of TGF (Tumor Growth Factor)

Increased Vascularization Increased Tumor Size Decreased blood/O2 supply for normal cells

Thickening/Lumping

Pearly/Shinny appearance Easy Fatigability

XII. NURSING CARE PLANS AND DRUG STUDIES

XII. DISCHARGE PLAN Medication

Instruct the patient to take home medication prescribed by the physician only. Carbomer eye gel OD-ODHS Erythromycin eye ointment OD TID Carboxymethylcellulose 0.5% eye drops Instill 1-2 gtts OD 2x a day

Remind to take the prescribed medicine, having a written reminder of the correct medication, time to take, and the right frequency of the medicine on the way home to establish assurance of medication compliance.

Exercise Instruct to avoid excessive activities that may result to stress. Just advise to perform range of motions and repetitive body movements for promotion of optimum health. Remind about the need for health promotion activities such as reading, watching T.V, etc. Assist the patient if she cannot tolerate to move..

Treatment Bed rest is advisable during the re-occurrence of fever phase.

Instruct to drink plenty of water or fluids that are available at home and eat nutritious diet.

Advised to look for re-occurrence of danger signs and symptoms and report immediately.

Health Teaching Have a nutritious and balance diet to provide enough calories and protein to prevent occurrence of weight loss and regain strength. Observe for possible complication that may happen during home treatment. Dont hesitate to discuss it with your physician. Gradually return to normal activities. Fatigue is common. Keep self from appropriate positioning to ease the pain. Instruct early exercise program to gently stretch the neck and back may be advised. Never force to lift something heavy and restrict movement to avoid worsening of pain. Self hygiene is always recommended. Out-Patient Follow-Up Care Instruct the family members to have a check-up or to consult physician once a while to monitor patients condition and for detection of recurrences and other complications that may arise on to it. The follow up check up would be one week prior to the discharged date.

Diet Instruct the family members to give the client protein rich foods such as meat, fish, eggs and nuts, green leafy vegetables, Vitamin C rich foods(guava and tomatoes and other citrus fruits), carbohydrates rich food (breads and rice), if eating is not restricted. Follow recommended dietary intake of the patient.