Cancer of The Larynx FINAL

LARYNGEAL CANCER Perpetual Help College of Manila SECTION A4AA MARCH 2011
Cancer of the Larynx
Cancer of the larynx is a malignant tumor in and around the larynx (voice box). Squamous cell carcinoma is the most common form of cancer of the larynx. Adenocarcinoma or sarcoma of the larynx is diagnosed less often. More than 10,000 new cases of cancer of the larynx occur annually. Cancer of the larynx occurs more frequently in men and than in women and it is most common in people between the ages of 50 and 70 years. The incidence of laryngeal cancer continues to decline, but the incidence in women versus men continues to increase. The disease is also about 50% more common among African Americans than among Caucasian Americans. Carcinogens that have been associated with laryngeal cancer include tobacco (smoke, smokeless) and alcohol and their combined effects, as well as exposure to asbestos, mustard gas, wood dust, tar products, leather and metals (Diet, Ramroth, Urban, et al., 2004). Other contributing factors include straining the voice, chronic laryngitis, nutritional deficiencies (riboflavin), and family predisposition. Laryngeal cancer can be classified into three categories: supraglottic (false vocal cords)), glottic (true vocal cords) and subglottic (downward extension of disease from the vocal cords) (National Cancer Institute, 2003). Two thirds of laryngeal cancer is in the glottic area. Supraglottic cancers account approximately one third of the cases, subglottic tumors for fewer than 1%. Glottic tumors seldom spread if found early, because of the limited lymph vessels found in the vocal cords. Approximately 25% to 50% of patients with laryngeal cancer present with involved lymph nodes. Metastatic disease from the true vocal cords is very rare, because they are devoid of lymph nodes. The prognosis for patients who have small laryngeal cancers without evidenced of spread to the lymph nodes is about 75% to 95%. Recurrence occurs usually within the first 2-3 years after diagnosis. The presence of disease after 5years is very often secondary to a new primary malignancy (National Cancer Institute, 2003)
DEMOGRAPHIC DATA
Full Name: Age: Sex: Address: Date of Birth: Place of Birth: Civil Status: Nationality: Race: Religion: Occupation:
Mr. XXX 73 years old Male Quezon City August 19 , 1937 Quezon City Married (Separated) Filipino Asian Roman Catholic N/A February 07, 2011 Time: 12:45 pm Difficulty and pain in swallowing Laryngeal Mass t/c malignancy
Date and time of Admission: Chief Complaint: Admitting Diagnosis:
Final diagnosis:
Laryngeal cancer
HISTORY OF PRESENT ILLNESS April 2010 The patient started complaining of difficulty of swallowing associated with pain occasionally. No difficulty of breathing noted. They consulted a doctor. CT scan was requested which revealed epiglottic mass. Operation was advised; due to financial problem operation was deferred. Patient was lost to follow up for his check-up, and the client confirmed that his difficulty of swallowing has lessened. (+) difficulty of swallowing noted with no other signs and symptoms. January 2011 The patient experienced episodes of nosebleed & blood in his sputum. Then again patient consulted medical attention. X-ray was requested and showed with normal findings. (+) Hoarseness (+) nosebleed (+) blood in sputum 3 weeks prior to admission patient started complaining of hoarseness, no difficulty of breathing noted. 4 days prior to admission patient consulted at OPD and they were advised for admission.
PAST MEDICAL HISTORY
The patient has incomplete immunization. He had an operation for herniorrhaphy when he was 50 years old. Whenever he experienced an illness they only consulted to an albularyo and no medical consultation was done afterwards. No known allergies to food and medication.
FAMILY HISTORY (+) Hypertension (+) Diabetes Mellitus (-) Heart Disease (-) Asthma (-) Cancer (-) PTB
SOCIAL HISTORY In the Eriksons stages of Psychosocial Development, he is in the stage of integrity vs. despair. At this stage, individual looks back over life and accept its meaning. The sense of integrity and fulfillment is observed. And lastly, the willingness to face death. The patient belongs to poor family. He is the youngest among four siblings. He got married at the age of 26 years old; they live in a congested area with a make-shift structured house. He is a smoker and alcoholic beverage drinker. He does not attend mass on Sundays and he doesnt consider himself as a religious person.
LIFESTYLE The patient sleeps for 6-7 hours a day. He drinks water 6-7 glasses per day. He walked around outside the house every morning. He watches television in the afternoon for 2-3 hours. They eat meals three times a day. He does household chores such as washing dishes and weeping the floor. The patient consumed one pack of cigarettes and three bottles per day as he stated before his confinement.
OCCUPATIONAL HISTORY The patient is elementary graduate. He started working at the age of 17 years old as a construction worker. He was the breadwinner in the family. When he got married he still works as a construction as his part-time job. Sometimes if there is no offered job for him, he works as a side walk vendor such as selling water and cigarettes.
ENVIRONMENTAL HISTORY They live in a congested area, one-story house made up of woods with one window on the front side of the house. Their area has no good drainage system that is why they easily get flooded during heavy rains. Their area has no proper disposal of garbage. And has no good source of water. Left over foods are been kept by covering it by plate.
A. Assessing appearance and mental status
1. The patient general appearance is not proportionate because of his condition and also due to aging. 2. He is slightly slouching when standing and doing some activities.
3. He is kempt; his relatives clean him every day. 4. He doesnt have body odor or any minor odor relative and also no breath odor. 5. He has distress noted related to his condition. 6. He doesnt have healthy appearance due to his disease. 7. He cooperates and able to follow instructions but sometimes not. 8. The patients affect is appropriate to the situation. 9. The patient has difficulty in talking because he has tracheotomy tube, uses gestures, sign language and pointing letters or numbers provided by the student nurse. 10. The patient response has relevance and organization of thoughts. B. Assessing the Skin 1. The client: a. The client has no history of itching. b. There is no presence of lesions except on the site of tracheotomy tube, no bruises, abrasions or pigmented spots but he has nevis and freckles on some parts of his body. Most seen in his face and chest area. c. He has no skin problems. d. He does not use any medications, lotions or any remedies. e. The client has dry skin. f. There is tendency for the client to bruise easily because of dry skin.
2. The color of the skin varies from light to deep brown. 3. The client has no edema. 4. .The client has no lesions. 5. The temperature is in the normal range 36.9 C and moisture in skin folds and axillae. 6. When pinched it easily springs back to normal.
C. Assessing the Hair 1. Inquire if client has any history of the following: a. He never used hair dyes, rinses or curling or straightening preparations. b. Never undergo chemotherapy. c. The client has no presence of disease. 2. The clients hair is evenly distributed. 3. He has a thin hair. 4. He has a dry hair. 5. There is no presence of infection. 6. The client has thin hair in his body and it is evenly distributed. D. Assessing the Nails a. The patient has a history of inguinal hernia. b. No peripheral circulatory disease c. No previous injury d. No severe illness Convex curvature; angle of nail plate about 160 degrees The patient has a light to deep brown color black pigmentation in longitudinal streaks Rough texture with excessive thickness of grooves and furrows and intact epidermis of finger and toe nails Prompt return of pink or usual color in 3 seconds.
1. 2. 3. 4.
E. Assessing the Skull and Face 1. Inquire if client has any history of the following: a. No lumps, itchiness, and dandruff noted b. No noted loss of consciousness, dizziness, seizures, headache, facial pain, or injury 2. Patient skull size is 21 inches, rounded and symmetrical. 3. The patient has no nodules, masses and depression noted 4. Symmetric of structure and of the distribution of hair 5. No presence of edema around the eyes 6. Symmetric facial movements F. Eyes structures and visual acuity 1. a. Positive on family history of Diabetes, Hypertension, but negative in Blood Dyscrasia. b. No eyes disease, injury or surgery c. Never visit an ophthalmologist d. Never use eye medication e. Never use contact lenses or eyeglasses
f. No hygienic practices of eye problems g. No current symptoms of eye problems 2. Eyebrows hair is equally distributed and symmetrically aligned; skin is intact and equal movement. 3. Equally distributed, straight and slightly outward 4. Skin intact, no discharged, no discoloration, lids close symmetrically; approximately 14 blinks/minute, bilaterally blinking, when lids are open, no visible sclera above corneas and upper and lower borders of corneas are slightly covered. 5. Transparent, capillaries sometimes evident and no lesions. 6. Shiny and smooth red in color. No lesions or nodules 7. No edema or tenderness over lacrimal glands 8. Transparent, shiny, smooth and details of iris is visible. 9. Patient blinks when the cornea is touched, indicating that the trigeminal nerve is intact. 10. Brown in color, round in shape and 4mm symmetry of size G. Ears and Hearing 1. a. No family history of hearing problem or loss b. No presence of any ear problems or pain c. Never complains of ringing in ears. No medication history d. No hearing difficulty e. Never use of corrective hearing device 2. Same color as the facial skin, symmetry or size and position 3. Firm and not tender, pinna recoils after it is folded 4. Dry cerumen during inspection, no skin lesion or discharged
H. Assessing the Nose and Sinuses 1. a. The patient has no history of allergies. b. There is no difficulty of breathing through the nose. c. The patient has no sinusitis. d. He has no injuries in nose or even in face. e. He experience nosebleed before he admitted to the hospital but no changes in smell. 2. Symmetric and straight, no discharge or flaring and uniform color but presence of black heads. 3. No lesions and tenderness, or masses in any areas 4. Air moves freely on the patient breaths through the nares. 5. There is no presence of redness, swelling growth and discharge. 6. No tenderness during the palpitation of maxillary and frontal sinuses
I. Assessing the Mouth and Oropharynx 1. Inquire if the client has any history of the following: a. No routine pattern of dental care. b. Never been consulted to the dentist c. When the patient having a mouth sore it takes 5-7days, for it to heal but during P.A no present mouth sore. d. No dentures 2. Symmetrical contour, dark red in color. 3. Inner lips and buccal mucosa is dark red in color, smooth and wet. No presence of lesions 4. Upper teeth are 12 and lower teeth are 10, with dental carries, yellow in color with black in other area. Gums is dark red in color no dentures. 5. His tongue is in the central position, red with white patches/ pigmentation on the middle. Moves freely and no tenderness 6. Smooth tongue base with prominent veins 7. Smooth with no palpable nodules 8. Same color of buccal mucosa and floor of mouth 9. Using penlight there is no lesions noted dark red in color In hard palate lighter pink, and more irregular, smooth palate is smooth and soft.. 10. Positioned in midline of soft palate 11. Dark red and smooth posterior wall 12. Lightly dark pink in color, no discharged and normal size The tonsil is color dark pink 13. Patient shows difficulty of swallowing.
J. Assessing the Neck 1. Inquire if the client has any history of the following: a. There was no any problems with neck lumps based on the CT scan there is a mass on the suprahyoid and infrahyoid portions of the larynx b. There was neck pain but no stiffness. The patient has elective tracheostomy to avoid unnecessary manipulation of tumor. The patient has never been diagnose with thyroid problems. The patient has a surgery direct laryngoscopy with biopsy. Neck muscles equal in size; head centered Head coordinated, smooth movements with no discomfort There is no palpable lymph nodes but presence of tenderness on neck. Trachea has in central placement in midline of neck; spaces are equal on both sides Thyroid gland not visible on inspection, and lobes may not be palpable
2. 3. 4. 5. 5.
K. Assessing the Thorax and Lungs 1. Inquire if client has any history of the following: a. Family has no history of cancer b. The patient has no allergies c. There is no history of Tuberculosis d. He is a chain smoker e. He had medications taken for current problems, he took Robitussin for cough, and self-medications for other illnesses 2. The shape and symmetry of thorax has an anteroposterior to transverse diameter in ratio 1:2, and chest symmetric 3. Spine is vertically aligned 4. Skin is intact; he also has uniform temperature 5. Posterior chest has full and symmetric chest expansion 6. The patient has bilateral symmetry of vocal fremitus 7. Thorax percussion notes resonate, except over scapula. Lowest point of resonance is at the diaphragm. Excursion is 2 inches to 2 1/2 inches. 8. Chest auscultation has vesicular and bronchovesicular breath sounds 9. Presence of crackles and hoarseness. 10. Anterior chest is full symmetric excursion; thumbs normally separate 2inches to 2 inches. 11. Same as posterior vocal fremitus 12. Percussion notes resonate down to the sixth rib at the level of the diaphragm but are flat over areas of heavy muscle and bone, dull on areas over the heart and the liver, and tympanic over the underlying stomach 13. Adventitious breath sounds (crackles).
L. Assessing the Heart and Central Vessels 1. Inquire if the client has any history of the following: a. Patient has a family history of Hypertension and Diabetes b. No past history of any heart disease. c. He has no present symptoms indicative of heart disease d. He has no presence of disease that affects the heart e. He had a smoking lifestyle habit that is risk factor for heart disease 2. He has no pulsations nor lift or heave in the tricuspid 3. S1: Usually heard at all sites Usually louder at apical area S2: Usually heard at all sites Usually louder at base of heart Systole: silent interval; slightly shorter duration than diastole at normal heart rate (60 to 90 beats/min) Diastole: silent interval; slightly longer duration than systole at normal heart rates S4: in many older adults
4. The carotid artery has symmetric pulse volumes; Full pulsations, thrusting quality; Quality remains same when client breathes, turns head, and changes from sitting to supine position; Has elastic arterial wall; There is no sound heard on auscultation 5. The jugular veins not visible M. Peripheral vascular System 1. Inquire if the client has any history of the following: a. According to the patient he has no history of any heart disorder, varicosities, arterial diseases and hypertension. b. The patient does some household chores. c. The patient started smoking and drinking since he was 16 years old. 2. Peripheral pulses on both sides are symmetric pulse volumes and have full pulsations. 3. Presence of distension and nodular bulges and valves. When limbs are elevated, veins collapse. 4. There is no sign of phlebitis. Limbs not tender and symmetric in size. 5. Hands and feet are color brown because of unhygienic. Skin temperature not excessively warm or cold. No edema. N. Breast and Axillae 1. a. b. c. d. e. f. g. h. i. j. k. l. m. 2. 3. 4. 5. inquire if the client has any history of the following: There is no breast mass. No pain or tenderness in the breasts. No discharge/s from the nipple. No history of medication. (estrogen replacement therapy) (mother, sister, aunt He consumes liquor, 3 bottles/day Ordered diet is clear-liquid N/A N/A N/A N/A N/A The breast is even with the chest wall. The skin of the breasts is uniform in color, smooth and intact. Round oral bilaterally the same, color varies widely. No masses and lesions. Both nipples are Rounded, everted, and equal in size; similar in color, soft and smooth, both nipples point in same direction. no discharge and lesions. 6. Axillary, subclavicular and supraclavicular lymph nodes does not have any palpable tenderness and masses. 7. Breast has no palpable tenderness, masses, nodules or nipple discharge/s.
O. Assessing the Abdomen 1. a. b. c. d. e. f. g. h. 2. 3. 4. 5. 6. 7. 8. 9. Determine the clients history of the following: No incidence of abdominal pain. Abnormal bowel elimination. He only defecates once in 5 days There are no changes in appetite. No food intolerances. Food ingested in the last 24 hours was only milk. No sign and symptoms No previous problems and treatment. Rounded abdomen, symmetric countour. Symmetric movements on respiration. No visible vascular pattern. Audible bowel sounds. There is absence of arterial bruits and frictions rub. Tympany over the stomach and gas-filled bowels; dullness, especially over the liver and spleen. 6-12 cm in the mid- clavicular; 4-8 cm at the mid sterna line. No tenderness; relaxed abdomen with smooth, consistent tension. No tenderness. Border feels smooth. Not palpable.
P. Musculoskeletal System 1. Inquire if the client has any history of the following: a. There is no muscle pain according to the patient during the physical assessment done to him. b. The patient has IV lines at the right hand. The patient can only performed less movement. c. The patient experiences no any previous sports injury. No fasciculation and tremors and also no muscles and tendon contractures. Normally firm during palpation of muscle at rest. The patient smooth coordinated movements during muscle palpation when he is active. The patient has equal strength on each body side. There are bone deformities at the both small fingers of his hands of the patient. There is no tenderness or any presence of edema in any area of his body. There is no presence of tenderness, swelling or nodules and the joints has less movements.
2. 3. 4. 5. 6. 7. 8.
Q. Neurological System Assessment 1. Inquire if the patient has any history of the following: a. No presence of pain in the head, back or even at the extremeties. b. The patient is oriented to time, place or persons. c. The patient cannot speak due to Tracheostomy tube.
2. 3. 4. 5.
d. No any history of loss of consciousness, fainting, convulsion, trauma, tingling, tremors or tics, paralysis uncontrolled muscle but there is a presence of numbness in his feet. e. Theres no problem in smell, vision, taste but there is presence of numbness in his both foot and hearing disability. Can hardly speak due to his tracheostomy tube. No disorientation to time place and person. The patient has lapses in memory when answering the questions. Eye opening is Spontaneous, motor response is to verbal command because he can follow command, and his verbal response is no response because of his tracheostomy.
R. Assessing Female genitals and Inguinal area. The patient is male. S. Assessing the Male genitals andInguinal area 1. inquireif the client has any history of the following: a. the patient voids 6 times before and now 4 times only. b. no history of abdominal pain c. none symptoms of sexually transmitted disease d. the patients has history of hernia when he was 50 years old,. e. no family history of nephritis, malignancy of prostate or mali1gnancy of the kidney. 2. Refused. 3. Refused 4. Refused 5. Refused 6. Refused 7. Refused 8. Refused T. Assessing the rectum and anus 1. Inquire if the client has any history of the following a. The client defecates after 5 days because he ate small amount of food. b. There is no history of colorectal cancer c. Never experience to defecate with occult blood. d. Not assessed because the client refused. 2. The client refused. 3. The client refused.
U. Vital signs Normal Actual Findings Blood pressure 120/80 mmHg 140/100 mmHg On the disease process, any condition that may affect the cardiac output, blood volume, blood viscosity has direct effect on the blood pressure. The patient was in distress during the assessment Interpretation/Analysis
(Kozier, B. (2004). Fundamentals of Nursing p. 510). Temperature 36.5-37.5 C 36.9 C Febrile
Inflammation is a local, nonspecific defensive response of the tissues to an injurious or infectious agent. It is an adaptive mechanism that destroys or dilutes the injurious agent, prevents further spread of the injury, and promotes the repair of damaged tissue.
(Kozier, B. (2004). Fundamentals of Nursing p. 634). Pulse rate 60-100 cpm 82 cpm Normal Range (Kozier, B. (2004). Fundamentals of Nursing p. 496). Respiratory rate 16-20 bpm 19 bpm Several factors that increase respiratory rate include stress and increase environmental temperature.(Kozier, B. (2004). Fundamentals of Nursing p. 506).
V. Serum type Entered: 02/7/11 (08:12) Report Printed: 03:34 Test ALT Result 39 u/L Normal Values 30-65 u/L Analysis Normal Interpretation - The result is within normal range
--------------------------------------------------------------------------------------------------------------------Serum type Entered: 02/7/11 (08:12) Report Printed: 03:34 Test Total Protein Result 77.8 g/L Normal Values 64-82 g/L Analysis Normal Interpretation - The result is within normal range - The result is within normal range -High globulin is found in many types of inflammation, certain infections and in chronic liver disease and infections. A/G Ratio may be decreased due to liver dysfunction. - The result is within normal range - The result is within normal range -Low sodium level are
Albumin
37.7 g/L
34-50 g/L
Normal
Globulin
40.1 g/L
30-32 g/L
HIGH
A/G Ratio
0.9
1.1-1.6
LOW
Blood Urea Nitrogen Creatinine
3.6 mmol/L
2.50-6.1 mmol/L
Normal
71 umol/L
53.00-115.0 umol/L 135-148 mmol/L
Normal
Sodium
133 mmol/L
LOW
Potassium
3.8 mmol/L
3.60-5.20 mmol/L 15.00-37.00 u/L
Normal
AST
31 u/L
Normal
uncommon and most often occur as a side effect of taking meds that make you urinate more, such as diuretics. - The result is within normal range - The result is within normal range
----------------------------------------------------------------------------------------------------------------------------------------Serum type Entered: 02/8/11 (08:29) Report Printed: 21:12:33 Test Glucose Result 5.8 mmol/L Normal Values 3.9-6.1 mmol/L Analysis Normal Interpretation - The result is within normal range - The result is within normal range - The result is within normal range - The result is within normal range - The result is within normal range
Cholesterol
3.7 mmol/L
0-5.2 mmol/L
Normal
Triglycerides
1.3 mmol/L
0.4-1.7 mmol/L
Normal
HDL Cholesterol
1.01 mmol/L
0.91-1.56 mmol/L 1.89-3.09 mmol/L
Normal
LDL
2.1 mmol/L
Normal
--------------------------------------------------------------------------------------------------------------------BLOOD TYPING February 7, 2011 Result: B POSITIVE --------------------------------------------------------------------------------------------------------------------HEMATOLOGY Februaruary 7, 2011 Test Hemoglobin Result 121 Normal Values 120-170 g/L Analysis Normal Interpretation - The result is within normal range -Decreased hematocrit indicates vitamin or mineral deficiency, recent bleeding and liver cirrhosis. - The result is within normal range - The result is within normal range - The result is within normal range - The result is within normal range - The result is within normal range - The result is within normal range - The result is within normal range - The result is within normal range - The result is within normal range - The result is
Hematocrit
0.354
.40-.57
LOW
WBC Count
9.4
5-10^g/L
Normal
Segmenters
.699
.50-.70
Normal
Lymphocytes
.227
.20-.40
Normal
Monocytes
.070
0-0.07
Normal
Eosinophils
.003
0-0.05
Normal
Basophils
0.001
0-0.2
Normal
MCV
86.4
80.9-99.9 fl
Normal
MCH
29.6
27-31 pg
Normal
MCHC
34.2
33-37 Y
Normal
Platelet Count
362
150-400 10^g/L
Normal
within normal range --------------------------------------------------------------------------------------------------------------------April 6, 2010 Age/Sex: 73 Dx: Supraglottic mass T/C malignancy STUDY: CT SCAN OF THE NECK WITH EMPHASIS ON THE LARYNX PLAIN AND WITH CONTRAST Findings: There is a soft tissue mass seen in the suprahyoid and infrahyoid positions of the epiglottis protruding into the laryngeal vestibule with indefinite extension into the left aryepiglottic fold. It measures about 3.6x3.0x2.1 cm (length x width x height) The preepiglottic space, paralaryngeal, anterior and posterior commisures appear intact. The true and false vocal cords are not unusual No evident of the hyoid bone, laryngeal cartilages are noted The parotid and submandibular glands are normal The rest of the cervical spaces and its facial planes are intact No evident cervical lymphadenopathy is seen IMPRESSION: EPIGLOTTIC MASS AS DESCRIBED, MALIGNANCY CONSIDERED
Examination Requested: CHEST PA Date: 1/14/11 Radiographic No. 4007-11 RADIOGRAPHIC REPORT: BOTH LUNG FIELDS ARE CLEAR HEART IS NOT ENLARGED NO OTHER REMARKAABLE CHEST FINDINGS IMPRESSION: NORMAL CHEST
The patients general appearance is disproportionate because he is slightly slouching when standing and doing some activities due to aging. He has distress noted related to his condition and due to hospital bills increasing and threat of death. The patient has difficulty of talking because he has tracheostomy tube. The patiet has dry skin with possible tendency to bruise easily. The patient has thin and dry hair due to aging. He experiences nosebleed before he was admitted to the hospital. He experienced epistaxis and hemoptysis due to dry nasal passages because of hoarseness of voice. Patients mouth has dark red in color, inner lips and buccal mucosa is dark red in color with crakes due smoking, patient verbalizes difficulty of swallowing. Upper teeth are 12 and lower are 10, with dental carries, also due to smoking. He underwent Elective tracheostomy to avoid unnecessary manipulation of tumor. On CT scan there was a mass on the suprahyoid and infrahyoid portions of the larynx. There was neck pain but no stiffness noted. He had a smoking lifestyle for 47 years, 1 pack of cigarette per day. Patients bowel elimination is abnormal and usually defecates after 5 days. Patients laboratory shows that his globulin and WBC is high, because he has infection and inflammation. The patients A/G ratio is low which means patient is most likely to have liver dysfunction as evidenced by high intake of alcohol, with 21 bottles per week. Sodium level is low because low sodium levels are uncommon and most often occur as a side effect of taking meds. Hematocrit level is low due to as being anemia. There are many reasons for anemia. Patients CT scan impression is epiglottic mass as described, malignancy considered.
POSSIBLE NURSING DIAGNOSIS: Ineffective airway clearance related to retained secretions as evidenced by crackles. Constipation related to irregular bowel dysfunction as evidenced by clients verbalization. Infection related to post operative procedure as evidenced by increased WBC and decrease hemoglobin. Impaired swallowing related to mechanical obstruction as evidenced by tracheostomy tube. Anxiety related to situational crises such as hospital bills & threat of death as evidenced by restlessness.
ACTUAL NURSING CARE PLAN ASSESSMENT DIAGNOSIS INFERENCE Subjective: Ineffective Surgical airway alteration in clearance the airway related to excessive mucus production Excessive as mucus manifested secretion Objective: by (+) Crackles adventitious (+) Cough breath (+) Excessive sounds sputum Blocking of (+) airway Restlessness RR 24 (+) Nasal Flaring Difficulty of breathing PLANNING GOAL: After 8 hours of nursing intervention the patient will be able to demonstrate techniques in performing airway clearance and promote wellness INTERVENTION 1. Monitor respirations and breath sounds, noting rate and sounds. RATIONALE 1. Indicative of respiratory distress or accumulation of secretions EVALUATION GOAL: After 8 hours of nursing intervention the patient will be able to demonstrate 2. To open and techniques in maintain performing airway and to airway take advantage clearance and of gravity promote decreasing wellness pressure on the diaphragm OBJECTIVE: and enhancing After 1 hour of drainage of nursing ventilation to intervention different lung the patient will segment. maintain a patent airway 3. To clear and be able to airway when expectorate excessive or secretions viscous secretions are . blocking or when client is unable to cough effectively
2. Position client in fowlers position
OBJECTIVE: After 1 hour of nursing intervention the patient will maintain a patent airway and be able to 3. Suction expectorate secretions PRN secretions
4. Encourage deep 4. To maximize breathing and effort coughing exercises
5. Increase fluid intake at least 2-3 liters
5. Proper hydration can help liquefy secretions and improve clearance
6. Support 6. To improve reduction/cessation lung function of smoking
7. Provide information about the necessity of expectorating secretion versus swallowing
7. To report changes in color and amount in the event that medical interventions maybe needed 8. Forced expiratory breathing (Huffing)
8. Demonstrate/ assist client in performing specific airway clearance techniques
9. Encourage and 9. Prevents provide and reduces opportunities for fatigue rest and limit activities to level of respiratory tolerance 10. Give expectorants/ bronchodilators as ordered 10. Expectorants helps in improving clearance of secretion and bronchodilators aids in proper gas exchange
POTENTIAL NURSING CARE PLAN ASSESSMENT DIAGNOSIS INFERENCE PLANNING INTERVENTION Subjective: Risk for OBJECTIVE: 1. Assess clients aspiration After 1 hour ability to swallow of nursing and strength of intervention gag reflex and the patient evaluate amount will maintain and consistency a patent of secretions. airway and be able to 2. Observe for Objective: expectorate neck and facial secretions edema RATIONALE 1. Help determine presence and effectiveness of protective mechanism EVALUATION OBJECTIVE: After 1 hour of nursing intervention the patient will maintain a patent airway and be able to expectorate secretions
2. Client with head/neck surgery or tracheal/ bronchial injury is at risk for airway obstruction and inability to handle secretion. 3. Facilitate clearing airway in emergency situations 4. TO clear secretions while reducing potential for aspiration of secretion 5. Supine position have been shown to be independent risk factors for the development of aspiration pneumonia
3. Maintain operational section equipment at bedside 4. Suction ET tube as needed and avoid triggering of gag mechanism when performing suction 5. Avoid keeping client in supine position when on mechanical ventilation
February 14, 2011 Sir/Maam: Good Day! We the nursing students from Perpetual Help College of Manila, NCM 204 section A4AA would like to ask for your consent to conduct our physical assessment, this will be used for our grand case presentation this coming march 01, 2011. This case presentation will serve as our preparation and added knowledge for our nursing career. We wish to have your time for today and with cooperation. Although you may not receive direct benefit from your participation, others may ultimately benefit from the knowledge obtained in this study. You will not be identified in any reports on this. Records will be kept confidential to the extent provided by the hospital. However, the list of panel responsible for monitoring this study will review the datas collected. If significant new knowledge is obtained during the course of this study which may relate to your willingness to continue participation, you will be informed of this knowledge. Your participation in this study is voluntary. Even after you sign the informed consent document, you may decide to leave the study at any time without penalty or loss of benefits to which you may otherwise be entitled. One copy of this document will be kept together with the records of this study.
I have read the information given above. I hereby consent to participate in the study.
Printed Name and Signature
Modifiable Risk Factors: Combined effects of alcohol and tobacco use Paint fumes Food dust Cement dust Chemicals Straining of voice Chronic Laryngitis
Non-Modifiable Risk Factors: Age Gender (more commonly male) Stress Hereditary -obese
Exposure to chemical carcinogen Cellular Transformation
Normal cell transform into cancer cells
Accumulation of squamous cell carcinoma Carcinoma of true vocal cords (Glottis)
Metastasis develops
Formation of mass on laryngeal area
Laryngeal Mass
Spread of Carcinoma
Laryngeal Cancer
DISCHARGE PLANNING
Medications- Patient is for discharge, with the following take home medicine such as: Tramadol 50mg/ 1 tab PRN for moderate pain Ranitidine 150 mg/ twice a day at bedtime Metronidazole 375 mg/ 1 tab per day
Instruct the patient to religiously take the ordered medications at the right time, dosage, and frequency.
Exercise - Once home, it is possible to tire more easily than usual to begin with, so it is important to take it easy. Strenuous exercise and lifting should be also avoided. Light exercise such as walking, deep breathing and coughing exercise are recommended. Normal activities, including returning to work, can usually be resumed after about a week.
Treatment . For tracheostomies older than 1 month, clean technique is used for tracheostomy care. Stress the importance of good hand washing technique to the care giver. Tap water may be used for rinsing the inner cannula. Teach the care giver the tracheostomy care procedure and observe a return demonstration. Inform the caregiver of the signs and symptoms that may indicate an infection of the stoma site or lower airway. Consequently, to prevent other complications, she must have his lifestyle and diet modified.
Health Teaching - Explain to patient what to expect afterwards. As the anesthetic wears off, there is likely to be some pain. The anesthetist will prescribe painkillers. Suffering from pain can slow down recovery, so it's important to discuss any pain with the doctors or nurses. On discharge, patient must advise about caring for the tracheostomy, hygiene and bathing, and will arrange an outpatient appointment for the tracheostomy to be removed, if necessary. Some people which do not need to be removed.
Instruct patient to comply with the take home medications that would be given by his physician. Remind him to complete the full course of the antibiotic treatment. Encourage patient to do the recommended light exercises such as walking. Avoid doing strenuous activities which could slow down his recovery. Encourage him to comply with the dietary modifications. Explain to patient to refer for unusual signs and symptoms of any untoward feelings immediately regarding to her condition.
OPD Follow-up Remind patients that regular check-ups are important to ensure that the patient condition is constantly monitored by the doctor. If any of the following symptoms are noted, he should contact her doctor: the stoma start to bleed stoma become more painful, red, inflamed or swollen pain is not relieved by the prescribed painkillers a fever develops.
These could be signs of an infection that may need to be treated with antibiotics
Diet- Patient must remember, most importantly, stops smoking and reduce drinking, if you currently have these habits. However, according to this study, greatly increasing your intake of fiber, in particular fiber from vegetables, may be helpful for protecting against laryngeal cancer. Amazingly, even for those who have a long history of smoking and drinking, eating more fiber still helps reduce risk of laryngeal cancer. Spiritual- Provides emotional support coming from family. Encouraged the patient to participate in the community services to promote social supportive relationship.
PRESENTED BY: Mayo, Raissa May Meneses, Millete Miculob, Van joseph Nebrida, Karen Osite, Caroll Panilo, Ma. Angelica Pascual, Maria Lorena Quijano, Maris Angela Saspa, Darwin

Cancer of The Larynx FINAL

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Cancer of The Larynx FINAL

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LARYNGEAL CANCER Perpetual Help College of Manila SECTION A4AA MARCH 2011

Cancer of the Larynx

Date and time of Admission: Chief Complaint: Admitting Diagnosis:

PAST MEDICAL HISTORY

A. Assessing appearance and mental status

(Kozier, B. (2004). Fundamentals of Nursing p. 510). Temperature 36.5-37.5 C 36.9 C Febrile

Blood Urea Nitrogen Creatinine

53.00-115.0 umol/L 135-148 mmol/L

3.60-5.20 mmol/L 15.00-37.00 u/L

0.91-1.56 mmol/L 1.89-3.09 mmol/L

2. Position client in fowlers position

4. Encourage deep 4. To maximize breathing and effort coughing exercises

5. Increase fluid intake at least 2-3 liters

5. Proper hydration can help liquefy secretions and improve clearance

6. Support 6. To improve reduction/cessation lung function of smoking

7. Provide information about the necessity of expectorating secretion versus swallowing

8. Demonstrate/ assist client in performing specific airway clearance techniques

Printed Name and Signature

Exposure to chemical carcinogen Cellular Transformation

Normal cell transform into cancer cells

Accumulation of squamous cell carcinoma Carcinoma of true vocal cords (Glottis)

Formation of mass on laryngeal area

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