Nasopharyngeal Carcinoma

Case Study

Demographic DataCASE NO: 116***NAME: Mr. MAGE: 46 yrs oldSEX: MaleDIAGNOSIS:

Nasopharyngeal Carcinoma

Physical Assessment

Vital Signs;

BP- 120/70 mmhgRR- 32/minPR- 72/minTemp- 36.8’C

Integument

Skin allergy noted at upper extremities

With good skin turgorWith capillary refill test

(1-2secs)

HeadNo palpable lesion on the head

With right side facial numbness

Always complaining of headache

EyesPale palpebral conjunctivaPERRLA (Pupils Equally Round and Reactive to Light Accommodation)

Sometimes experienced blurring of vision and light sensitivity

EarsSymmetrical in shape and size

With occasional ear painDiminished hearingTinnitus noted at times

Nosewith epistaxiswith right nasal obstructionwith mass, reddish in color seen through rigid endoscope

cough and cold noted, whitish secretions

Mouth

Hard and soft palate grayish in color.

Difficulty in uttering words noted

Mouth breathing

Neck and Throat

With painless, enlarged lymph nodes in the neck

Sore throat noted

Respiratory/ Chest

Chest is symmetricUse of accessory muscles when breathing

Crackles noted both lung fields

Extremities

No edema found on both legs

No lesions noted

Medical History

Past Medical History

No major medical problems

Common colds- treated with water therapy

Ignored sneezing

Socio-economic Lifestyle Sedentary lifestyle Smoking 1 pack in a day

No restrictions for food- Filipino foods

Shoe factory worker store keeper(construction materials) store keeper (KSA) store keeper(hosp)

Family History

Legend▪ - father

▪ mother

▪ aunt

▪ cousin

lung cancer

NPC

prostate cancer

Father’s side Mother’s side

3rd1st 2nd

Present Medical History

1st visit- (July 24, 2010)

Dr. H.Chief complaint- nose bleeding

Nasopharyngoscopy doneDx- deviated nasal septumAdvised for CT –scan (rejected by insurance)

2nd visit (April 10, 2012)Dr. PCc: persistent Rt. Nasal obstruction with recurrent epistaxis

Nasopharynggoscopy done

Nasopharyngoscopy

Examination;Mass, dark round, fill nasopharynx,

seems to be originating from right side:

Dx- bleeding mass nasopharynx inverted

papilloma/hemangioma.

Dr. P. advised CT scan & histopathology

Prescribed Otrivin nasal Spray

3rd visit- (August 26, 2012)

Ct- scan done with contrast

Nursing Responsibilities

Explain the procedure to the client

Assess allergy to dye.

Secure consent for the procedure.

Insert IV cannula aseptically as the dye will inject in through the vein.

Inform that the client may feel hot sensation when dye is injected.

Encourage the client to drink plenty of water after the procedure.

CT Image Result (Aug 26, 2012)

NORMAL CLIENT MR. M

CT Result

Possible dx;Nasopharyngeal carcinomaGranulomatous lesions

Sept. 2, 2012

Biopsy was done Confirmed the dx of nasopharyngeal cancer

Nursing Responsibilities

Explain the procedure to the client.

Informed consentMake sure all the equipments needed are available.

Send tissue samples at the laboratory in a sterile container with formalin.

Advised by Dr. P.

Chemotherapy

Radiotherapy

Introduction

Nasopharyngeal cancer

Anatomy & Physiology

Etiology

Nasopharyngeal Cancer

Types of TumorsBenign- non cancerous

Malignant- cancerous

Staging of NPC

2 Ways of Staging Cancer

TNM SystemNumber system

Tumor Nodes Metastasize

T0- no tumor N0- no lymph nodes M0- not spread in other parts of the body

T1- within the nasopharynx, oropharynx or nasal cavity

N1- cancer cells in lymph nodes on one side of the neck, not > 6cm across

M1- cancer has spread to other parts of the body.

T2- spread into the areas next to nasopharynx, not spread into the bone

N2- cancer cells in lymph nodes on both sides of the neck, > 6m across

T3- spread into the sinuses

T4- spread in one or more;•Cranial nerves•Hypopharynx•Eye or surrrounding tissue•Bony spaces

N3-•N3a- cancer cells in one or more lymph nodes , one node is > 6cm across•N3b- there are cancer cells in the supraclavicular area

Number Staging of CancerNo. Stage DescriptionStage 0

Stage 1

Stage 2

Carcinoma in situ

Not spread

Larger cancer, affects more than half the area of nasopharynx

No. Staging DescriptionStage 3

Stage 4

4a4b4c

Spread ;OropharynxThroatNearby b0nes and air cavities

Advanced stage

-grown within the skull-nearby tissues and bones-spread in other parts of the body ex. lungs

Risk FactorsDiets - in salt cured fish and meat

Epstein Barr Virus Infection

Genetic Factors MaleAge 30- 55 yrs oldAsian

Signs and Symptoms

Painless and enlarged lymph nodes in the neck

Nasal obstructionsEpistaxisDiminished hearingTinnitusRecurrent Otitis MediaCranial Nerve Dysfunctions Sore throatHeadache

Diagnostic TestMedical History and physical

AssessmentFiberoptic Endoscopic

Examination

Ct Scan

MRI (Magnetic Resonance Imaging)

Biopsy

Treatments

Chemotherapy Cisplatin - drug of choice

Side EffectsAnorexiaConstipation Bone marrow damageHair lossIncrease risk of infectionMouth soresNausea and vomitingFatigue

Radiation TherapyExternal Beam Radiation/ Brachytherapy

Side Effects▪ Skin burns▪ Confusion▪ Difficulty of swallowing▪ Fatigue▪ Hairloss▪ Headaches▪ Nausea and vomiting▪ Rashes and other skin problems▪ Weight loss

Surgery

Complications

BleedingInfectionDifficulty breathingTumor spread to other organs

9 Warning Signs of Cancer

Cancer Precaution

C changes in bowel & bladder habits

A a sore that does not heal U unusual bleeding

T thickening lump in breast or elsewhere

I indigestion or difficulty in

swallowing O obvious changes in moles or warts

N nagging cough and hoarseness

U unexplained anemia

S sudden weight loss

Pathophysiology

Unknown Predisposing Factors;AsianMen; 30-50yrs oldHereditary

Precipitating Factors;Cigarette SmokingAlcohol AbuseOccupational exposureDiet; salt preserved foods

Genetic Mutation

Uncontrolled cell division at squamous cells that line the

nasopharynx

Pre- malignant cell

Untreated

Cell continues to divide out of control and all daughter cells produced with

the same ability

Increased in malignant and appearance

Cancer cells confined in the cells of the

throat (nasopharynx greatly affected)

Signs and symptoms

occur

Drug Study

Name Classifications

Actions Indications

Contraindicati

ons

Adverse

Reaction

Nursing Consider

ations

Generic Name:Xylometazoline

Brand Name:Otrivin

Decongestant

It works by constricting blood vessels that leads to a decrease in congestions. The formulation acts directly on the blood vessels in the nose and sinuses

Nasal congestions due to cold, sinusitis

Respiratory allergies

High blood pressure

Heart disease

Irregular heartbeat

Thyroid problems

Diabetes

Pregnant woman

Glaucoma

Dizziness

Sweating

Tiredness

Slow heart rate

Advice the client not to use drug > 3-5 days, longer use could cause damage to nasal tissue

Advice client that this drug should not be use with MOA.

strictly follow the instructions ordered by the doctor

Name Classifications

Actions Indications

Contraindications

Adverse Reactions

Nursing Considerations

Generic Name:Cisplatin

Brand Name:Platinol

Antineoplastic

May cross link strands of cellular DNA and interfere with RNA transcription, causing an imbalance of growth that leads to cell death

Head and neck cancer

Others:Prostate cancer

Hypersensitivity do drug

Severe renal disease

Hearing impairment

Renal failure

Liver failure

Ocular toxicity

neuritis

Monitor intake and output

Advise pt. to watch for signs of infection

Tell pt to immediately report ringing in the ears and numbness in hands or feet

Prioritization of

Nursing Problem

Nursing Diagnosis

Ineffective Airway Clearance related to nasal blockage as manifested by presence of mass in nasal cavity as seen through rigid endoscopy.

Ineffective Breathing Pattern related to nasal obstruction as manifested by respiratory irregularities and mouth breathing.

Activity Intolerance related to weakness

Therapeutic Regimen management; Readiness for enhance as manifested by frequent asking questions regarding disease treatments.

Impaired verbal communication related to inability of air pass through the nose as manifested by mouth breathing and difficulty of uttering words

Knowledge deficit, management of therapy and treatment related to misinterpretation of information.

Risk for Imbalanced Nutrition less than body requirements as a result of nausea and vomiting, side effects of chemotherapy.

Risk for Impaired skin integrity related to side effects of chemotherapy and radiotherapy.

Risk for situational Low self esteem.

Nursing Care Plan

Cues Nsg Dx Planning

Interventions

Rationale

Evaluation

Subjective;“I cant’ breathe through my nose’ as verbalized by the client.

Objective;•Mouth breathing•Clogged nose•Resp irregularities RR- 34/min•With right nasal bleeding

Ineffective Airway Clearance related to nasal blockage as manifested by mass seen through rigid endoscopy

At the end of 8 hrs of duty the client’s respiratory irregularities will improve.

Proper breathing technique demonstrated like breathing through mouth in perfect rhythm

Otrivin 0.1%, 1 nasal spray given each nostril 3 x a day as prescribed by the physician.

To improve respiratory difficulties.

Helps to reduce symptoms of nasal congestions, works by narrowing the blood vessels in the lining of the nose.

After the 8 hrs of duty client respiratory irregularities improved as manifested by:RR- 26/min

Health teaching done as follows;•Client need to stop smoking

•Use mask when expose to dust and chemicals•Eat foods rich im CHO, fats.

Limit intake of salty, grilled, fried and smoked foods

Smoking triggers more complications like difficulty of breathing and possible infections.

The client is immunocompromised.

To increase clients’s stamina since he is still working.Since this foods are contributing factors of having NPC

Nursing

Health Teachin

g

Advised client to use protective equipments like mask when exposed to dust and any chemicals.

Encouraged to strictly follow treatment regimen.

Encouraged to eat small frequent feedings to reduce nausea, take anti- nausea medications as prescribed

Encouraged to drink at least 1- 2 liters of fluid every 24 hrs, unless the client are instructed to limit fluid intake.

Drinking alcohol beverages should be kept to a minimum or avoided completely

Encouraged to stop smoking completely

Encouraged to get plenty of rest and maintain good nutrition.

Conclusion

Presented a case of 46 yrs old client with chief complaint of right nasal obstruction, nose bleeding. Nasopharyngoscopy shows presence of mass in nasal cavity with CT scan and histophatology report pertaining to common diagnosis; nasopharyngeal carcinoma

Treatment for nasopharyngeal carcinoma involves combination of radiation and chemotherapy for this client.

Early detection of nasopharyngeal cancer is vital for treating the disease to prevent its development and metastasis.

The stage of cancer, size of tumor, the client’s age, general health and compliance to treatment regimen are factors that can affect prognosis.

Cisplatin is the drug of choice in this case.

Nursing management includes provision of an emotional supportive environment, encouragement for strict compliance of treatments are important.

Bibliography

Gleeson, michael Otorhinolaryngology; Head and Neck Surgery. (editon 2008)

Htpp://www.cancer.gov/cancertopics

Htpp://www.medicenter.com/nasopharyngealcancer/articles

Modalities of surveilance in treated nasophayngeal cancer. Head and Neck Surgery.

Jeanelyn Virtucio

Speaker

Presented by: EENT department