INTRODUCTION

Gastric cancer The stomach is part of the digestive system. It is located in the upper abdomen, between the esophagus

and the small intestine. Stomach cancer is also called gastric cancer. The stomach is a J-shaped organ in the upper abdomen. It is part of the digestive system, which

processes nutrients (vitamins, minerals, carbohydrates, fats, proteins, and water) in foods that are eaten and helps pass waste material out of the body. Food moves from the throat to the stomach through a hollow, muscular tube called the esophagus. After leaving the stomach, partly-digested food passes into the small intestine and then into the large intestine.

The wall of the stomach is made up of 3 layers of tissue: the mucosal (innermost) layer, the muscularis (middle) layer, and the serosal (outermost) layer. Gastric cancer begins in the cells lining the mucosal layer and spreads through the outer layers as it grows.

Gastric cancer is a disease in which malignant (cancer) cells form in the lining of the stomach. Age, diet, and stomach disease can affect the risk of developing gastric cancer. There are three ways that cancer spreads in the body. Most (85%) cases of gastric cancer are adenocarcinomas that occur in the lining of the stomach (mucosa). Approximately 40% of cases develop in the lower part of the stomach (pylorus); 40% develop in the middle part (body); and 15% develop in the upper part (cardia). In about 10% of cases, cancer develops in more than one part of the organ.

Stomach cancer can spread (metastasize) to the esophagus or the small intestine, and can extend through the stomach wall to nearby lymph nodes and organs (e.g., liver, pancreas, colon). It also can metastasize to other parts of the body (e.g., lungs, ovaries, bones).Stomach cancer occurs twice as often in men and it is more common in people over the age of 55.Stomach cancer is cancer that occurs in the stomach — the muscular sac located in the upper middle of your abdomen, just below your ribs. Your stomach is responsible for receiving and holding the food you eat and then helping to break down and digest it.

Risk factors for gastric cancer include the following: • Eating a diet high in salted, smoked foods and low in fruits and vegetables.• Eating foods that have not been prepared or stored properly.• Being older or male.• Smoking cigarettes.• Having a mother, father, sister, or brother who has had stomach cancer.

The three ways that cancer spreads in the body are:• Through tissue. Cancer invades the surrounding normal tissue.

o Through the lymph system. Cancer invades the lymph system and travels through the lymph vessels to other places in the body.o Through the blood. Cancer invades the veins and capillaries and travels through the blood to other places in the body.

When cancer cells break away from the primary (original) tumor and travel through the lymph or blood to other places in the body, another (secondary) tumor may form. This process is called metastasis. The secondary (metastatic) tumor is the same type of cancer as the primary tumor. For example, if breast cancer spreads to the bones, the cancer cells in the bones are actually breast cancer cells. The disease is metastatic breast cancer, not bone cancer.

StagesIn stage 0, abnormal cells are found in the inside lining of the mucosal (innermost) layer of the stomach wall. These abnormal cells may become cancer and spread into nearby normal tissue. Stage 0 is also called carcinoma in situ.

In stage I, cancer has formed. Stage I is divided into stage IA and stage IB, depending on where the cancer has spread.

• Stage IA: Cancer has spread completely through the mucosal (innermost) layer of the stomach wall.

• Stage IB: Cancer has spread: o Completely through the mucosal (innermost) layer of the stomach wall and is found in up to 6 lymph nodes near the tumor; oro To the muscularis (middle) layer of the stomach wall.

Stage II In stage II gastric cancer, cancer has spread:• Completely through the mucosal (innermost) layer of the stomach wall and is found in 7 to 15 lymph nodes near the tumor; or• To the muscularis (middle) layer of the stomach wall and is found in up to 6 lymph nodes near the tumor; or• To the serosal (outermost) layer of the stomach wall but not to lymph nodes or other organs.

Stage III gastric cancer is divided into stage IIIA and stage IIIB depending on where the cancer has spread.• Stage IIIA: Cancer has spread to:

o The muscularis (middle) layer of the stomach wall and is found in 7 to 15 lymph nodes near the tumor; oro The serosal (outermost) layer of the stomach wall and is found in 1 to 6 lymph nodes near the tumor; oro Organs next to the stomach but not to lymph nodes or other parts of the body.

• Stage IIIB: Cancer has spread to the serosal (outermost) layer of the stomach wall and is found in 7 to 15 lymph nodes near the tumor.

Stage IV In stage IV, cancer has spread to:

• Organs next to the stomach and to at least one lymph node; or• More than 15 lymph nodes; or• Other parts of the body.

CURRENT TREND

Cancer is the third leading cause of morbidity and mortality in the Philippines. Leading cancer sites/types are lung, breast, cervix, liver, colon and rectum, prostate, stomach, oral cavity, ovary and leukemia. There is at present a low cancer prevention consciousness and most cancer patients seek consultation only at advanced stages. Cancer survival rates are relatively low a recent assessment revealed shortcomings in the Cancer Control Program and urgent recommendations were made to reverse the anticipated ‘cancer epidemic’. There is also today in place a Community-based Cancer Care Network which seeks to develop a network of self-sufficient communities sharing responsibility for cancer care and control in the country. Those cancers whose major causes are known (where action can therefore be taken for primary prevention), such as cancers of the lung/larynx (anti-smoking campaign), liver (vaccination against hepatitis B virus), cervix (safe sex) and colon/rectum/stomach (healthy diet). DOH–RCR was evaluated as the first population-based survival data for Filipinos. Lung cancer had the lowest survival and breast cancer had the highest .Five-year survival in excess of 40% was observed for only three cancer sites: oral cavity, colon and breast. For all other sites, survival was less than 30%. Owing to the small number of cases in each category, no distinct impact of age on relative survival could be perceived for most cancer sites.

REASONS FOR CHOOSING THE TOPIC

Our group chose this case because it is our first time to encounter this kind of illness and we are fond of knowing the important things to be considered, terms to be discussed, appropriate nursing interventions and medical management for this case. And as much as possible, we want to explore on different kinds of cases within our every exposure so we can expand and enhance our knowledge, skills, and understanding of different diseases to our subject.

IMPORTANCE OF THE STUDY CASE

The important of this case study is for student to be familiar with the gastric cancer, how it starts, and what are the signs and symptom; especially how to prevent, treat and manage patients by giving nursing interventions, medication for treatment, and providing rapport. Conducting this case study is also important to be able to incorporate concept and enhance manage in medical-surgical nursing, and apply appropriate nursing management for patients with gastric cancer accurately and efficiently.

MAJOR GOALS OBJECTIVE

Our major goals for this may include attaining an optimal level of nutrition, preventing infection, maintaining skin integrity, enhancing coping mechanism, adjusting to changes in body image, acquiring knowledge of and skills in self care, and to prevent further complications.

NURSING PROCESSASSESSMENT

PERSONAL DATAName: Mr. XAge: 59 yrs. oldSex: MaleCivil Status: MarriedAddress: Sitio Pangulo Carangian Tarlac cityOccupation: Truck DriverReligious Affiliation: Roman CatholicRole in the Family: FatherDate of Birth: January 14, 1950Place of Birth: PangasinanNationality: FilipinoHealth Care Financing: Through the helped of his childrenUsual source of medical care: PHILHEALTHDate of Admission: January 20, 2010

LIFESTYLE AND ENVIRONMENT STATUSMr. X lives in a two storey house with his wife at Carangian Tarlac City. He has 3

children and all of them have their own family and still helping their father for hospitalization. He is a truck driver of a lumber store here in Tarlac. According to him as a driver there was an instance that sometimes when the “call of nature” called him, he can’t stop the truck right away especially when he’s in the middle of the road. According to his wife, he loves to drink soda and coffee. Sometimes he eats his meals not on time because of his work. He also eats foods rich in cholesterol. He has no vices at all.

FAMILY HISTORY OF HEALTH AND ILLNESS

Great grand parents3rd Degree

Grandparents2nd Degree

Parents

1st Degree Siblings

HISTORY OF PAST ILLNESS

He does not suffer to any chronic disease. During his past years he only have cough, flu, and fever that last only for 3-7 days only. His vaccination was completed during his younger years. He only had intermittent abdominal pain that was started early 2009. During the occurrences of his abdominal pain he consulted some clinics and the doctor told him that he only had gastritis ulcer so that they prescribed him ranitidine and cefuroxime. And sometimes he only bought over the counter medicines as needed.

December 22, 2009 he was admitted at Talon General Hospital because he can’t tolerate

his abdominal pain. In the said hospital X-ray was performed in the same date. The next day, he was undergone endoscopy at Central Luzon Doctors Hospital, they stated that gastric mass poorly differentiated adenocarcinoma with signet ring features. Then, January 07, 2010 CT- Scan was performed at Ramos General Hospital. The result stated that the gastric mucosa on the fundus and proximal body is thickened and irregular indicative of infiltrating gastric mass lesion.

He was not involved in any accidents.

HISTORY OF PRESENT ILLNESS

He was apparently well until July 2009 when he felt abdominal pain almost every day but tolerable. He lost 9kg within 6 months. His condition then progressed to recognizable vomiting undigested non bilious food after meals especially with solids. Ever since then, he experienced anorexia and was afraid to eat but he could still tolerate fluids. Blood in his stool also found out. He could tolerate fluid and small amount of soft diet. He was treated by medication when he consults his doctor but still he felt intermittent abdominal pain.

On December 2009, Abdominal Ultra sound and X-ray was performed and the result revealed that he has gastric mass. CT- Scan was performed as well and endoscopy for the second opinion and the result was he had gastric adeno carcinoma.

Last January 20, 2010 he was admitted at Tarlac Provincial Hospital. Exploratory laparotomy also performed for jejunostomy for feeding of the patient last January 31, 2010. Ever since diagnosed with the disease although he really don’t know his whole condition, it has affected his quality of life and peace of mind. He has been having insomnia and feels he is a burden to his family financially and emotionally.

PHYSICAL ASSESSMENT

ASSESSMENT TECHNIQUE ACTUAL FINDING NORMAL FINDINGS EVALUATION

Skin

Inspection and palpation

Pale, Xerosis as evidence by flaking, generalized skin tenderness , poor skin turgor

Uniform whitish pink to brown color according to race, dry with a minimum of perspiration, skin should not be tender

Abnormal

Hair

Inspection and palpation

black thick and evenly distributed, brittle hair dull hair, with no parasites noted

Hair varies from dark to pale blonde based on the amount of melanin present should not be brittle and absent from any parasite, may feel thin, straight, coarse, thick, or curly; it should be shinny and resilient when traction is applied and should not come out in clumps in your hand

Abnormal

ScalpInspection Smooth absent from

nodules and masses no parasites

Pale white to pink to light skinned individuals no infestations or lesions dandruff (seborrhea) may be present

Normal

Nails

Inspection Pale, Beau’s line noted Have pink cast in light skinned individuals and are brown I dark skinned individuals. Capillary refill of 2-3 sec. the nail surface should be smooth and slightly rounded or flat. Curved nails are a normal variant. Nail thickness should be uniform throughout, with no splintering or brittle edges

Abnormal

Face

Inspection Oval, symmetrical; cachexia noted

The facial features should be symmetrical. Both palpebral fissures should be equal and the nasolabial fold should present bilaterally. The shape of the face can be oval, round, or slightly square. There should be no edema, disproportionate structures, or involuntary movements.

Abnormal

Eyes

Inspection Pale conjunctiva The bulbar conjunctiva is transparent with small blood vessels visible in it. It should appear white except for a few small blood vessels w/c are normal. No swelling, exudates, foreign bodies, or lesions are noted

Abnormal

Ears

Inspection Centrally positioned, pale color, proportion to the head, dry cerumen

The ear should be match the flesh color of the rest of the patients skin and should be positioned centrally and in proportion to the head. Cerumen should be moist and not obscure the thympanic membranes. There should be no foreign bodies, redness, drainage, deformities nodules or lessions

Abnormal

Nose (external) Inspection Symmetrically, no swelling, bleeding, lesions, and masses

The shape of the external nose can vary greatly among individuals. normally, it is located symmetrically in the midline of the face and is without swelling, bleeding, lesions, or

Normal

masses

Lips

Inspection Palpation

Pale ,dry, flaccid The lips and membranes should be pink and moist with no evidence of lesions or inflammations. Lips should not be flaccid an lesions should not be present

Abnormal

Mouth Inspection Acetony breath The breath should smell fresh Abnormal

TongueInspection Pale, symmetrical,

partially hydratedSymmetrical, w/o lesions and moist

Abnormal

GumsInspection Pale In light skinned individuals the gums

have a pale red stippled surface Abnormal

ThoraxInspection Pectus carinatum In the normal adult is wider from side

to side than from front to back. Thorax is slightly elliptical in shape

Abnormal

LungsAuscultation Clear breath sounds

( - ) rales ( - ) wheeze Clear from any breath sounds

Normal

HeartAuscultation Regular rhythm, normal

heart rate, no murmurRegular rhythm, normal heart rate of 80-100bpm, no abnormal sounds

Normal

Abdomen

Auscultation Inspection Percussion Palpation

Dull tympany, scaphoid abdomen, Generalized tenderness palpable, mass hypogastric mid quadrant, scaphoid abdomen, absent bowel sounds

In the normal adult the contour is flat or rounded. High pitched sounds of 5-30 times per minute

Abnormal

Muscle size and shape

inspection palpation

Atropy Hypotonicity

Muscle contour will be affected by the exercise and activity pattern of the individual. On palpation the muscle should feel smooth and firm even to the phase of relaxation

Abnormal

DIAGNOSTOC AND LABORATORY PROCEDURE

ABDOMINAL ULTRASOUNDHOSPITAL: Talon General Hospital (TGH)DATE PERFORMED: 12/22/09FINDINGS:The stomach is distended with a homogenous echoic structure caudally and posteriorly suggestive of a mass in the stomach measuring 15.6cm in thickness. A gastric neoplasm sarcoma? May be considered. Clinical correlation and upper G.I. series or gastroscopy may be help.IMPRESSION: Suggestive of a gastric mass.

CHEST X-RAYHOSPITAL: Talon General Hospital (TGH)DATE PERFORMED: 12/22/09IMPRESSION: The lung fields are essentially clear

ENDOSCOPYHOSPITAL: Central Luzon Doctors Hospital (CLDH)DATE PERFORMED: 12/23/09FINDINGS: Gastric mass poorly differentiated adenocarcinoma with signet ring features.

CT SCAN DATE PERFORMED: 01/07/10HOSPITAL: Ramos General Hospital (RGH)PROCEDURE: Whole abdomen CT scanFINDINGS: The gastric mucosa on the fundus and proximal body is thickened and irregular indicative of infiltrating gastric mass lesion.IMPRESSION: Consider gastric tumor lesion most likely neoplasm unremarkable liver, gallbladder, pancreas, spleen, kidney and urinary bladder.

LABORATORY RESULTS

CBCDATE: 01/27/10

NORMAL VALUE FINDINGS INTERPRETATIONWBC 4.1-10.4 11.8 HIGHLYM 0.6-4.1 0.4 LOW

GRAN 2.0-7.8 10.0 HIGHRBC 4.20-6.30 4.05 LOWHGB 120-180 107 LOWHCT .37-.51 .32 LOWMCV 80.0-97.0 80.7 NORMALMCH 26.0-32.0 26.4 NORMAL

MCHC 310-360 327 NORMAL

BLOOD CHEMISTRY (ELECTROLYTES)DATE: 01/20/10

ELECTROLYTES NORMAL VALUE FINDINGS INTERPRETATIONSODIUM 136-142 130.8 LOW

POTASSIUM 3.8-5.0 3.69 LOWCHLORIDE 45-103 102 NORMAL

TPAG DETERMINATIONDATE: 01/27/10

NORMAL VALUE FINDINGS INTERPRETATIONTOTAL PROTEIN 60-78 57.37 LOW

ALBUMIN 32-45 23.37 LOWGLOBULIN 23-35 34 NORMAL

ANATOMY AND PHYSIOLOGY

The pylorus is the region of the stomach that connects to the duodenum

It is divided in two parts:The pyloric antrum , which connects to the body of the stomach.The pyloric canal, which connects to the duodenum.

The pyloric sphincter, or valve, is a strong ring of smooth muscle at the end of the pyloric canal and lets food pass from the stomach to the duodenum.

PATHOPHYSIOLOGY

Book based:Gastric mass metastasis ETIOLOGIC PREDISPOSING

- Chemicals - Age- Viruses - Sex- Genetic - Stress- Physical - Occupation

Malignant Cell “Cancer Cell”

Adenocarcinoma Gastro intestinal tract

Obstruction PYLORUS

CANCER CELL

Break, Spill from Lymphatic and Blood vessel primary tumor

Deposited within normal cell

METASTASIS

Patient based:

PATIENT

Lifestyle Hereditary History of cancer (1st Degree)

On and Off Abdominal pain

Anorexia and vomiting

Gastric mass Cancer Cell (Adeno carcinoma)

Gastric outlet obstruction Gastric biopsy

GASTRIC MASS METASTATIC

CUESNURSING DIANOSIS

SCIENTIFIC EXPLANATION

PLANNING INTERVENTIONS RATIONALE EVALUATION

S-“Nahihirapan akong huminga.” As verbalized by the patient

O-Pale in appearance

-DOB

-(+)cough

-w/ O2 via nasal canula

- V/S as followsBP-100/70 mmHgPR-82bpmRR-22bpmTEMP-39.1’C

Ineffective airway clearance related to presence of secretion

In ability to clear secretions or obstructions as from the respiratory tract to maintain a clear airway

After 1-2˚ of nursing interventions, the patient will be able to demonstrate absence of secretion and improved the oxygen exchange

-Monitor the respiratory pattern

-Place patient in semi-fowlers position.

-Administer O2 inhalation via nasal cannula.

-Place pt. to a comfortable position

-Teach the patient deep breath and perform controlled coughing.

-Administer bronchodilators as prescribed by the doctor.

-Secretion in the airway the respiratory rate will -To maintain O2 in blood and to help patient to established normal breathing-Facilitate effective breathing

-Facilitate effective breathing

-This technique can help increase sputum clearance and decrease cough spasms.-Bronchodilators decrease airway resistance.

After 1-2˚ nursing interventions, the patient was able to demonstrated absence of reduction congestion and improve oxygen exchange

CUES NURSING DIANOSIS

SCIENTIFIC EXPLAINATION

PLANNING INTERVENTIONS RATIONALE EVALUATION

S-“Nilalagnat ako.” As verbalized by the patient

O-weak in appearance

-flushed skin -warm to touch

-dry skin

-V/S as followsBP-90/60 mmHgPR-82bpmRR-22bpmTEMP-39.1’C

Hyperthermia related to present illness (gastric metastasis)

Body temperature elevated above normal range

After 1-2˚ of nursing interventions, the patient temp will be back from the normal range from 39.1C to 37.5

-Asses the history of the patient.

-Monitor the vital sign.

-Performed tepid sponge bath.

-Instruct the patient to increase fluid intake.

-Administer paracetamol as prescribe by the Physician.

-To know the other possible causes in acquiring kind of disease.

-Use for baseline data

-Tepid sponge bath minimizes the heat of the patient by way of evaporation.

-To prevent dehydration.

-To lower the heat of the patient faster.

After 1-2˚of nursing intervention, the patient latest temp is 37.5

-continued TSB

CUESNURSING

DIAGNOSISSCIENTIFIC

EXPLANATIONPLANNING INTERVENTIONS

RATIONALEEVALUATION

S- “Sumasakit yong tiyan ko” As verbalized by the patient.

O- Weak in appearance -P.S. of 8/10 -With O2 inhalation -Swollen stomach -With jejunostomy tube feeding -With IFC intact -With surgical incision on abdomen -Poor muscle tone-assume in supine position most of the time

Chronic pain r/t ulceration and necrosis

Unpleasant sensory and emotional experience arising from actual potential tissue damage resulted from the tumor that erodes blood vessels and pressure on tissue that causes tissue damage.

After 4-8˚ of proper nursing intervention the pain will be decrease from pain scale of 8/10 to 2/10.

-Assessed for conditions associated with long term pain

-Used pain rating scale

-Encouraged pt. To use positive affirmation Ex. “Iam healing”

-Encouraged used of non-pharmacological methods of pain control Ex. “Deep breathing”

-Administered pain reliever as ordered

-To identify pt. With potential to pain lasting beyond normal healing

-To obtain patient assessment of pain

-To limit focusing on pain

-To promote relaxation

-It may help to reduce the pain

-After 4-8˚ of proper nursing intervention the patient pain is now decrease to tolerable level AEB pain scale of 4/10

-Goal partially met

CUES NURSING DIAGNOSIS

SCIENTIFIC EXPLANATION

PLANNING INTERVENTIONS RATIONALE EVALUATION

S- “ Nawawalan na ako ng pag asang gumaling” as verbalized

O-Weak and pale appearance-Lack of initiative-W/ oxygen inhalation-W/ jejunostomy tube feeding-W/ IFC intact-W/ surgical incision on abdomen-Assume in supine position most of the time

Hopelessness r/t prolonged activity restriction creating isolation

Subjective state in w/c an individual sees limited or no alternatives or personal choices available and is unable to mobilize energy on own behalf

After 2-3˚ of proper nursing interventions, patient will be able to participate in diversional activities of own choice

-Established a therapeutic relationship showing positive regard for the client

-Expressed hope to client and encouraged so to do so

-Assisted client/family to become aware of factors/situation leading to feelings of hopelessness

-Provided positive feedback for actions taken to deal w/ overcome feelings of hopelessness

-Client may then feel safe to disclose feelings and feel understood and listened to

-Client may not identify in own situation

-Provides opportunity to avoid/ modify situation

-Encouraged continuation of desired behavior

After 2-3˚of proper nursing interventions, pt. was able to participated in diversional activities of own choice

CUESNURSING

DIAGNOSISSCIENTIFIC

EXPLANATIONPLANNING INTERVENTIONS RATIONALE EVALUATION

S- “Hindi ako masyado makagalaw.”As verbalized by the patient.

O- Weak and pale appearance-W/ oxygen inhalation-W/ surgical incision on abdomen-W/ jejunostomy tube feeding-Swollen stomach-Poor muscle tone-assume supine position most of the time

Activity intolerance r/t generalized body weakness

Insufficient physiological or psychological energy to endure or complete required or desired daily activities

After 4˚ of proper nursing interventions, pt. will be able to eliminate or reduce the negative factors affecting activity intolerance

-Noted reports of weakness, pain and fatigue

-Plan carefully balance rest period w/ activities

-Promote com fort measures

-Passive ROM rendered

-Changed position from side to side and semi-fowlers position alternately every 2 hr.

-Kept back dry

-Symptoms may be result of contributing intolerance of activity

-To reduce fatigue

-To promote relaxation

-Provide muscle strength and promote blood flow-To promote risk of developing pressure ulcer-To prevent the development of other complication like(pneumonia)

After 4˚ of proper nursing interventions, pt. was able to eliminate or reduced the negative factors affecting activity intolerance

MEDICAL MANAGEMENTIVF

IV FLUIDS DARE ORDERED CLASSIFICATION INDICATION

5% Dextrose in Lactated Ringers

Solution

January 20-23,2010January 25-27,2010

HYPERTONIC Intravenous solution for replacement therapy particularly in extra cellular fluid

and electrolyte deficit and acid base balance of the patient

Plain Lactated Ringers Solution

January 24,2010 ISOTONIC Fluid and electrolytes balance

NURSING RESPONSIBILITIES:PRIOR:

Verify with the doctors order Explain the indication to the patient

DURING: Label the IVF bottles and indicating the date and time it was started with the ordered regulation Maintain and regulated at the rate prescribed Handle IVF aseptically Changed solution and IVF tubing as per hospital policy

AFTER: Check the site for any signs/symptoms of infection

BLOOD TRANSFUSSION

TYPE OF BLOOD DATE ORDERED/ DATEPERFORMED/ DATE

CHANGE/

GENERAL DESCRIPTION INDICATION OR PURPOSE

Packed Red Blood Cells (PRBCs)

January 23,2010January 25,2010January 26,2010

This increased the amount of hemoglobin in the blood that can carry oxygen per fused from alveoli of the lungs to tissue. One unit of PRBCs typically will raise the hematocrit by 3-4% and the blood hemoglobin concentration by 1 gm/dl. PRBCs last in refrigeration for up to 42 days, but under the right condition they can be frozen for up to the decade.

Restore blood components and promotes homeostasis

Volume replacement in case with massive blood loss.

Use to increased the oxygen carrying capacity of blood in anemia’s, surgery or trauma.

To treat acute and chronic anemia

NURSING RESPONSIBILITIES PRIOR:

Check doctors order. Verify consent Explain the procedure Check the serial number of the blood type

DURING: Label the bottle date, time started and regulated Monitor vital signs Check for any signs of adverse reaction

AFTER: Checked the site for any sign and symptoms of infection

MEDICAL MANAGEMENT

DATE ORDERED/DATE PERFORMED/

GENERAL DESCRIPTION

INDICATIONS/ PURPOSES

Jejunostomy feeding Jan.31, 2010 A surgical procedure in which a hole is made in the small intestine in order to

insert feeding tube. A patient may receive jejunostomy if

he has difficulty in maintaining a healthy body

weight consuming food through the mouth. A

jejunostomy tube may be used to introduce nutritious liquids and medicines to the

body when the stomach is not fit for a feeding tube or in

order to drain unwanted gases and liquids from the stomach.

Typically recommended for patients who have pancreatic

disease, have difficulty emptying the stomach, or

have problem with the pulmonary aspiration of gastric contents, which

occurs when the stomach contents are inhaled into the lungs. As an alternative to a gastrostomy, in which the

feeding tube is inserted into the stomach, a jejunostomy may also be used when the stomach needs to be kept

strong for further surgeries.

MEDICAL MANAGEMENT

DATE ORDERED/DATE PERFORMED/

GENERAL DESCRIPTION

INDICATIONS/ PURPOSES

NASOGASTRIC TUBE Jan.20, 2010 An alternative feeding method to ensure adequate nutrition includes enteral (through the gastrointestinal system) methods. Enteral Nutrition (EN), also referred to as total enteral nutrition (TEN), is provided when the client is unable to ingest foods or the upper gastrointestinal tract is impaired and the transport of food to the small intestine is interrupted.

• For lavage• Empty the stomach

after a drug overdose or accidental poisoning

• Drain the stomach after major trauma, so the person can't inhale stomach contents into the lungs

• Keep the stomach relaxed after major surgery to the abdomen, such as an abdominal exploration

• Prevent distension of the stomach when the person has a bowel obstruction.

NURSING RESPONSIBILITIES: Explain the procedure, benefits, risks, complications, and alternatives to the patient or the patient's representative.

DRUG STUDY

DRUG NAMEROUTE/

DOSAGE/FREQUENCY

ACTION INDICATION CONTRAINDICATIONNURSING

RESPONSIBILITIES

Generic Name:CEFUROXIME

Brand Name:Zinacef

Classification:ANTIBIOTICS

750mg IVP q 8˚

Inhibits cell-wall synthesis,

promoting osmotic

instability; usually

bactericidal

Serious infection of the

lower respiratory and urinary tracts, skin and skin

structures infection bones

and joints infections septicemia meningitis,

gonorrhea and preoperative prophylaxis

Contraindicated in patient hypersensitive to drugs

-Check first the patient allergic to drugs

-Use cautiously in patient have hypersensitivity to penicillin because of possibility of cross sensitive with other Beta Lactam Antibiotics

-Absorption of cefuroxime is enhance by food

DRUG NAMEDOSAGE/ROUTE/

FREQUENCYACTION INDICATION CONTRAINDICATION

NURSING RESPONSIBILITIES

 Generic Name : RANITIDINE

Brand Name :Zantac

Classification:H2 receptor antagonist

50 mgIVP

q 8hrs

 Inhibits histamine H2 receptor site in the gastric parietal cell, w/c inhibits gastric acid secretions.

 Used in the management of various gastrointestinal disorders such as peptic ulcer.

 Hypersensitivity. History of acute porphyria. Long therapy.

 -Assess knowledge/teach  pt. appropriate use, possible side effects/appropriate interventions and adverse symptoms to report

-Use caution in presence  of renal and hepatic impairement

-Assess potential for interventions w/ other pharmacological agents, pt. may be taking (e.g increasing and decreasing levels/effects and toxicity)

DRUG NAMEDOSAGE/ROUTE/

FREQUENCYACTION INDICATION CONTRAINDICATION

NURSING RESPONSIBIITIES

 Generic Name :TRAMADOL

Brand Name :Ultram

Classification:Centrally active analgesic

50 mg/tabP.Oq 6˚

 Centrally acting analgesic not chemically related to opiods but binds o mu-opiod receptor and inhibits reuptake of norepinephrine and serotonin

 Moderate to severe pain

 Hypersensitivity. Acute intoxication w/ alcohol hypnotics, centrally acting analgesics, opiods, or psychotropic agents

 -Assess pt’s pain (location, type, character)  before therapy and regularly thereafter to monitor drug effectiveness (give before pain become extreme)

-Assess hypersensitivity reactions : pruritus, rash, and urticaria

-Monitor input-output ratio and check  for decreasing output w/c may indicate  retention

DRUG NAMEDOSAGE/ROUTE/

FREQUENCYACTION INDICATION CONTRAINDICATION

NURSING RESPONSIBILITIES

 Generic Name : PARACETAMOL

Brand Name :Tylenol

Classification:Antipyretics

300 mgIVPq 4˚

(PRN for temp : 38 C)

 Decrease fever by inhibiting the effectiveness of pyrogens on the hypothalamic heat regulating centers and by hypothalamic action leading to sweating and vasodilation.

 Relief of mild to moderate pain ; treatment of fever

 Hypersensitivity  ; intolerance to tartazine, alcohol, table sugar, saccharin

 -Assess pt’s fever or pain : type of pain, location, intensity, duration, temperature

-Assess allergic reactions : rash, urticaria, : if these occur, drug may have D/C

-Check I&O ratio : decreasing output may indicate renal failure (long term therapy)

DRUG NAMEDOSAGE/ROUTE/

FREQUENCYACTION INDICATION CONTRAINDICATION

NURSING RESPONSIBILITIES

Generic Name:  KETOROLAC

Brand Name :Toradol

Classification:Anti-inflammatory

30 mgIVP

q 8hrs

Primary mechanism of action responsible for ketorolac’s anti-inflammatory, antipyretic and analgesic effects is the inhibition of prostaglandin synthesis by competitive blocking of the enzyme.

Indicated for short-term management of moderate to severe postoperative pain

Pt’s w/ aprevious demonstrated hypersensitivityto ketorolac,and in pt’s w/the complete or partial syndrome of nasal polyps, or other allergic manifestations to aspirin or other non-steroidal anti-inflammatory drugs (due to possibility  of severe anaphylaxis

-Primary mechanism of action responsible  for ketorolac’s anti-inflammatory, antipyretic and analgesic effects is the inhibition of prostaglandin synthesis by competitive blocking of the enzyme.

-Ketorolac therapy should always be given initially by the IM or IV route. Oral therapy should be used only as a continuation of parenteral therapy.

-Advise pt to consult if rash, itching, visual disturbances, tinnus, wt. gain, edema, block stools, or influenza like syndromes (chills, fever, muscles aches, pain) occur.

DIET

DATETYPE OF

DIETGENERAL

DESCRIPTIONPURPOSE FOOD TAKEN

Jan.20,2010 DAT(Diet as

tolerated)

Any foods and drinks can be given by mouth

To provide essential nutrient to the body, and to help maintain body energy

Crackers, noodles, water

DATETYPE OF

DIETGENERAL

DESCRIPTIONPURPOSE FOOD TAKEN

Jan.31,2010 NPO(Nothing per

Orem)

No foods or drink should be given by mouth

Preparation for surgery and also done after surgery to prevent pulmonary aspiration

NONE

DATETYPE OF

DIETGENERAL

DESCRIPTIONPURPOSE FOOD TAKEN

Feb.01,2010 Soft diet A diet that is soft in texture low in residue easily digested and, well tolerated

It provide essential nutrients in the form of liquids like milk, and it help to sustain body nutrient

Milk(ENSURE)

EXERCISE

TYPE OF EXERCISE GENERAL DESCRIPTION PURPOSE/INDICATION

Passive ROM Passive ROM exercise are done for a person by helper. The helper d0oes the ROM exercise because the person cannot do them by himself

This exercise helps keep the joint and muscles as healthy as possible.

This can help to promote good blood low and flexibility of the extremities.

NURSING RESPONSIBILITIES:

Explain the purpose of the procedure Raise the patient bed to a height that is comfortable for him Do all ROM exercise smoothly and gently Stop ROM exercise if the person fells pain Take note of any complain of the patient about his physical condition after doing the procedure

SURGICAL MANAGEMENT

DATE PERFORMED

SURGICAL PROCEDURE

GENERAL DESCRIPTION

PURPOSE

January 31, 2010 Exploratory Laparotomy

Is a large incision made into the abdomen.

Is used to visualize and examine the structures inside of the abdominal cavity.

January 31, 2010 Gastric mass biopsy The removal of a small piece of living tissue from an organ or part of the body for microscopic examination.

Is an important means of diagnosing cancer from examination of fragment of tumor.

January 31, 2010 Jejunostomy A surgical operation in which the jejunum is brought through the abdominal wall and openend.

For jejunostomy feeding

January 31, 2010 Jejunotomy A surgical incision into jejunum

In order to inspect the interior or remove something within it.

NURSING RESPONSIBILITIESPRIOR: AFTER:

-Secure consent. -Flat on bed-Keep on NPO -Monitor vital signs-Explain the procedure -Keep on NPO for 8º

SOAPIE

S- “Nahihirapan pa akong huminga” As verbalized by the patient

O -Received on lying position-Conscious, coherent conversant -With O2 via nasal Cannula at 3LPM-with IVF DSLR IL @ 550 ml level reg. @ 30gtts/ min @ regulated hand-with productive cough -initial V/S as follows: BP-100/70mmHg RR-18cpm

PR-80bpm TEMP-37.5’C -Slowed movement noted -With intact IFC connected to urine bag at 300cc level of yellowish color of urine. -Pale in appearance.

A -Ineffective airway clearance r/t presence of secretion

P -After 1-2 of nursing interventions, the patient will be able to demonstrate absence reduction of congestion with respiration and improved 02 exchanges.

I -Elevated head of the bed and change position every 2’. -Emphasized deep breathing exercises.

- Administered 02 inhalation via nasal cnnula. -Promoted surface cooling by means of undressing

-Placed patient to a comfortable position -place patient in semi fowler position.

E -After 1-2’ of nursing interventions, the patient was able to demonstrated absence reduction of congestion with respiration of improved oxygen exchanged.

CONCLUSIONS

Therefore, effective student nursing care and client teaching to achieve outcome goals require that we understand the pathophysiology of the gastric cancer. We should know the natural history of the disease, such as; the normal course of disease progression, likely sites of metastasis, potential for effective treatment, side effects and the treatments. With a basic understanding of gastric cancer, we can build on that knowledge base by listening to the client’s history, reviewing the information provided in the medical record, consulting with colleagues, including student nursing peers and student nursing leaders.

RECOMMENDATION

We firmly believe, therefore, that the risk of gastric cancer and its mortality rate can be reduced, we need aggressive education regarding the signs and symptoms of gastric cancer. One of the major risk factors is diet — in particular, diets high in smoked foods, salted fish and meats, and pickled foods. Because the need for smoking, salting, and pickling foods decreased once refrigeration became readily available, the way in which food is consumed may also impact the risk of gastric cancer; for example, very hot-temperature foods and rapid food consumption may be detrimental, we advice him to avoid that kind of food!!. To our dear patient, we must recommend to eat a diet high in fresh fruits and yellow and green vegetables when he finally get home.

We recommend to our patient that providing tube care and preventing infection can be applied over the tube insertion site, to protects the skin around the incision from leakage and of gastric acid and spillage of feedings and also to prevent skin breakdown.

EVALUATION

At the end of this case study and proper nursing interventions provided the student nurses were able to achieved our expected outcomes such as; reports less anxiety, express fears and concerns about surgery, attains optimal nutrition by eating a small frequent meals high in calories, iron and vitamin C & A and also complies with enteral or parenteral nutrition as needed, performs self care activities and adjust to lifestyle changes.