I.

Introduction Cancer begins when cells in the body become abnormal and multiply without control or

order. These cells form a growth of tissue, called a tumor. A tumor can be benign (noncancerous) or malignant (cancerous). Nasopharyngeal cancer (also called nasopharyngeal carcinoma or NPC) is a disease of the nasopharynx, which is the air passageway at the upper part of the pharynx (throat) behind the nose. The pharynx is a hollow tube approximately five inches long that starts behind the nose and ends on top of the larynx (or voice box) and esophagus (the swallowing tube that goes from the throat to the stomach). The nostrils lead through the nasal cavity into the nasopharynx and an opening on each side of the nasopharynx (called the Eustachian tube opening) leads into the middle ear on each side. There are several types of benign nasopharyngeal tumors, including angiofibromas and hemangiomas that involve the vascular (blood-carrying) system and tumors in the lining of the nasopharynx that include the minor salivary glands. According to the World Health Organization (WHO), NPC is classified into three subtypes: Keratinizing squamous cell carcinoma (WHO type 1), Nonkeratinizing squamous cell carcinoma (WHO type 2), Undifferentiated or poorly differentiated carcinoma, including lymphoepithelioma and anaplastic variants (WHO type 3). Many types of nasopharyngeal cancer contain white blood cells, and these lymphocytes give it the name of lymphoepithelioma. EBV (Epstein-Barr virus) NPC is the most common epithelial cancer in adults. The detection of nuclear antigen associated with Epstein-Barr virus (EBNA) and viral DNA in NPC type 2 and 3, has revealed that EBV can infect epithelial cells and is associated with their transformation. The etiology of NPC (particularly the endemic form) seems to follow a multistep process, in which EBV, ethnic background, and environmental carcinogens all seem to play an important role. Lo et al. showed that EBV DNA was detectable in the plasma samples of 96% of patients with non-keratinizing NPC, compared with only 7% in controls.More importantly, EBV DNA levels appear to correlate with treatment response and they may predict disease recurrence, suggesting that they may be an independent indicator of prognosis. In adults, other likely etiological factors include genetic susceptibility, consumption of food (in particular salted

fish) containing carcinogenic volatile nitrosamines, and Exposure to chemical agents i.e. tobacco, drugs, and plant products. This case was a case of PT.A1, 46 years old from Basilan. Sulu, who is positive smoker and drinker for almost 20 years, who diagnosed with cancer last october 16, 2011 and confirmed diagnosis of nasopharyngeal carcinoma, differentiated Non-keratinizing type 4 (T1,N3,M0), ptb tx completed.

II. Health History Patient Profile Data: Name: PT. A1 Age: 46 yrs. Old Address: Basilan, Jolo Sulu Sex: Male Date of Birth: March 22, 1965 Place of Birth: Basilan, Mindanao Race/Religion: Muslim Marital Status: Married Education: College, (Undergradute) Occupation: Military Servant for 22years

Chief Complain: Dysphagia, body weakness and pain on the necks and joints, productive cough and vomiting Present History: Patient was admited last September 22, 2010, seven months prior to admission patient noted a palpable mass on the right lateral neck with no accompanied sign and symptoms only complained of dysphagia and hoarseness. The month after the mass gradually increases in sized, patient refused tohave further evaluation and management. August 15 of 2010 patient undergo biopsy of lateral neck and revealed that no malignant cell seen.after a month hard mass gradually increasing and punch biopsy was done which revealed positive for squamous carcinoma, differentiated, non keratinizing, then they decided to transfer the patient to Oncology department for radiotherapy.Last May 31, 2011 patient again undergo a biopsy procedure and revealed positive for multiple neck mass which is firm, non-tender and fixed. Patient also undergo nasopharyngolarygoscopy last June 29,2011 which revealed a positive mass bulging the nasopharyngeal are that cause positive drooling of saliva and positive paresis of right vocal cord. And in the latest biopsy done last June 23, 2011 revealed positive for metastatic carcinoma, undifferentiated 2.2 cm in widest diameter. His wound in lower extremities is positive for fungal organisms.

Past History The patient cannot recall his common childhood illness. He doesnt have diabetes milletus, heart problem and hypertension but he had been diagnosed to have pulmunary tuberculosis last September 1, 2010 and he is able to complete his medication regimen. He denies any allergies on foods and medication; he doesnt have injury and fructures in previous years. He doesnt undergo any surgical operation, aside from the invasive procedure he go throug in past months. Family History The patient doesnt have any family history of hypertension, diabetes milletus, asthma and cancer. Health management History Before the patient has beed hospitalized he smokes 60 packs per year and drinks alcohol, he cannot eats without condiments such as fish sauce or soysauce. He is also fun of drinking coffee, always in the morning and in the afternoon.And he always eats on time. Home environment and Psychosocial History They have one storey house, they lived in rural community, and the mode of transportation was tricycle and motor bike. They are far from market but near on Hospitals and churches. Their religion was Muslim and they go to their church once a week.

His perception to his self was a strong man because he is the one who works for his family, and he doesnt have any source of stress until he had the disease. If he wills able experience stress, he will read newspapers or watch television and smoke ciggaretes as his coping mechanism. His perception to his present illness, after the hospitalization he always hope that he will be fine and free from cancer, but as time goes by he feels body weakness and pains that causes his anxiety, he always prays and hoping for wellness. III. y Gordons Functional Health History:

Health Perception/ Health Management: The patient complies with medication; he took his medication on time. He also experiences anxiety because of pain and his body wekness. Nutritional-Metabolic He had feed throug parenteral nutrition, but he keeps and trying to feed his self through mouth even though he experienced difficulty of swallowing. y

Elimination His elimination is regular, sometimes twice a week and his urination was 2 times a day. y Activity Exercise Patient does not exercise and all vital signs are within the normal except for the pulse rate, he had tachycardia. y y Cognitive and Perceptual Patient has 20/20 vision. Hearing is not that good because of mass in nasopharynx, difficulty of swallowing is noted, and smell is good. Pain management; complained of pain 6/10 in pain scale. Cognitive functioning well. y Sleep & Rest Patients had sleep difficulty because of pain; he usually woke up during dawn. He sleeps 6hrs hours a day. His sleeping pattern was 9:00 pm- 3:00am or sometimes 5:00am. Then he takes a nap when he doesnt experienced pain. y Self-perception / Self-concept Patients has difficulty in speaking, he had hoarse voice and eyes perceive little optimism. Body posture is good. y Role-relationship Patient stress satisfaction with his partner and family, however patient perceives hospitalization alters hes father-role within the family for his family is in Mindanao. y Coping/Stress Tolerance Whenever had stress in the family, he will watch television or reading newspaper and smoke cigarretes as a coping mechanism. y Values-Belief

He is a Muslim and he usually go to church once a week together with his family and stops when he was been hospitalized but he keeps on praying every night.

IV. Review of the system Anatomy and Physiology

The nasopharynx is the upper portion of the pharynx (the tube at the back of the throat), and it lies just above the soft palate in the mouth. The nasopharynx is an important passageway that allows air to travel from the nose into the windpipe (trachea) and food into the foodpipe (esophagus). Located on the back wall of the nasopharynx are the pharngeal tonsils, also called the adenoids, which are a network of immune system cells that defend the mucus membranes of the mouth and airways. The nasopharynx also plays a role in hearing because openings at the side of pharynx connect the hearing tube to each ear. Pathophysiology: The precipitating factor that causes nasopharyngeal carcinoma is presence of EBV or Epstein-Barr virus. Secondary was eating of salted-prevervatives food in early childhood, smoking, alcohol abuse and other exposure to sun and a chemical that causes formation of benign bronchial epithelium tissue that transform into neoplastic tissue which is called nasopharngeal carcinoma. It has different types and one of this is squamous cells that irritates and causes obstruction of airway. When it is happens there is presence of sputum production and wheezing that leads to shortness of breath and chronic cough, on the other hand when obstruction happens because of bulging of mass in the nasopharyngeal area that causes compresion in the surrounding organs and irritation of the laryngeal nerves which causes hoarseness of voice. Because of the compression of esophagus, dysphagia happens. Further destruction of the organs happens that causes drooling os saliva and paresis of the part of vocal cords.

Pathophysiology

Precipitating Factor:
presence of (EBV) Epstein-Barr virus. Alsocalled human herpesvirus 4 (HHV-4), is a virus of the herpes family, which includes herpes simplex virus 1 and 2, and is one of the most common viruses in humans.

Precipitating Factor:
y Eating salt-preservatives foods (fish eggs, leafy vegetables and roots) during early childhood. Cigarrete smoking Alcohol abuse Poor oral hygine Long term exposure to sun Occupational exposure(chemicals)

y y y y y

Formation of benign bronchial epethelium tissue.

Transformation of benign tissue into neoplastic tissue

Nasopharyngeal cancer

Sputum production and wheezing

Irritation and obstruction of airway

Squamous cell carcinoma

Shortness of breath and chronic cough

Mass bulging the nasopharyngeal area

Compression of the surrounding organs (esophagus, vocal cords and salivary glands)

Irritation of the laryngeal nerve

-Difficuly of swallowing -drooling of saliva -paresis of right vocal cord

Hoarseness of voice Anorexia

Weight loss

V.

Laboratory Findings:

1. Biopsy of lateral neck Is a medical test involving the removal of cells or tissues for examination, It is the medical removal of tissue from a living subject to determine the presence or extent of a disease. The tissue is generally examined under a microscope by a pathologist, and can also be analyzed chemically. Result: (June 23, 2011) latest Positive for metastasic carcinoma, undifferentiated, 2.2 cm in widest diameter. Interpretation: Abnormal In the normal anatomy, there should be no presence of abnormal cell. 2. Nasopharyngolaryngoscopy A diagnostic medical procedure that uses a flexible fibre-optic endoscope to visualize the structures inside the nasal passages, including the sinus openings, the larynx and the vocal cords. Result: (June 29, 2011) Positive bulging mass nasopharyngeal area Positive drooling of saliva Positive paresis, right vocal cords. Interpretation: Abnormal Because of the bulging mass, surrounding organs are affected that causes paresis and abnormal function of it. 3. Computerized tomography scan Pictures of structures within the body created by a computer that takes the data from multiple X-ray images and turns them into pictures on a screen. CT stands for computerized tomography. The CT scan can reveal some soft-tissue and other structures that cannot even be seen in conventional X-rays. Using the same dosage of radiation as that of an ordinary Xray machine, an entire slice of the body can be made visible with about 100 times more clarity with the CT scan. Result: (November 12, 2011) Diffuse nasopharyngeal mucosal thickening more on right side. Multiple severely enlarge lymphoids on both side of the neck, larger on right.

Multiple enlarge lymphnodes on axilla, mediastinum and ride illeum. Interpretation: Abnormal There should be no palpable lymph nodes; presence of it indicates inflammation of body part or alteration on function of body part. 4. The complete blood count (CBC) The complete blood count is the calculation of the cellular (formed elements) of blood. These calculations are generally determined by special machines that analyze the different components of blood in less than a minute.A major portion of the complete blood count is the measure of the concentration of white blood cells,red blood cells, and platelets in the blood. Result: (August 04, 2011) Hgb: 10.1 g/dl Hct: 0.29 g/dl NV: 14.0-16.5 g/dl NV: 0.40-0.50 g/dl NV: 4.2-5.4 x 106 /udL NV: 4.4-11.3 x 106 /udL

RBC: 3.42 x 106 /udL WBC: 3.27 x 106 /udL

Interpretation: Abnormal decreased in Hgb, Hct, RBC, WBC indicates blood problems like anemia. 5. Blood chemistry test Is divided into groups of basic blood tests that give specific information about the condition of your organs. The tests are grouped according to body functions including metabolism, drug absorption, blood circulation and body fluid balance. Result: (August 04, 2011) Crea: 0.7 mg/dl NV: 0.6-1.2 mg/dl -within the normal SGOT: 20-25u/L NV: 5-40 U/L within the normal SGPT: 29u/L NV: 7-56 U/L within the normal

Total protein: 30-46g/dl NV: 60-85g/dl -abnormal Albumin: 2.7g/dl NV: 3.4 - 5.4 g/dl abnormal

AG/ratio: 1.40 NV: 1.7-2.2- within normal Globulin: 19-30 mg/dl NV: 75 to 300 mg/dL -abnormal Sodium: 132.0 mEq/L Potassium: 3.16 mEq/L NV: 135 to 145 mEq/L - abnormal NV: 3.7 to 5.2 mEq/L. - within normal

Interpretation: decreased total protein and albumin indicates edema or water retention while decreased total protein indicates malnutrition or malabsorption, decreased globulin may indicates the kidney does not filter the protein from the blood and it leaks into the urine. Low total body water and sodium levels may be due to dehydration, vomiting, diarrhea, over diuresis, or ketonuria. 6. Sputum microscopy A sputum sample is obtained by coughing deeply and expelling the material that comes from the lungs into a sterile cup. The sample is taken to a labarotory and placed in a medium under conditions that allow the organisms to grow. A positive culture may identify diseaseproducing organisms that may help diagnose bronchitis, tuberculosis, a lung abscess, or pneumonia. Result: (August 4, 2011) 725 puss cells, <25 epithilial cell gm(-) bacillus-feus Interpretation: Abnormal Moderate growth of klebsiella pneumoniae 7. Wound culture test A wound culture is a diagnostic laboratory test in which microorganismssuch as bacteria or fungi from an infected wound, are grown in the laboratory on nutrient-enriched substance called mediathen identified. Wound cultures always include aerobic (with oxygen) culture, but direct smear evaluation by Gram stain and anaerobic (without oxygen) culture are not performed on every wound. Result: (July 27, 2011) KOH-postive for fungal elements Interpretation: Abnormal

VI.

Drug Study

Drugs name Ketorolac Brand name: Remopain Classification : NSAIDs

Action

Indication

Contraindication

Adverse Reaction

Nursing Intervention Assess pts pain before and 1hr after treatment: type, location, intensity and ROM. Monitor for adverse reaction: CNS, drowsiness, insomia and syncope. Assess for Gi bleeding: blood in sputum, stool and emesis. Give with food or milk to decrease gastric symptoms.

Analgesic, antiinflammatory and antipyretic. Inhibits prostaglandin synthesis by inhibition of cyclo-oxygenase enzyme. It also inhibits leukotriene synthesis, help stabilize lysosoma; membranes and exert anti- bradykinin activity.

Short term management of moderate to severe post-operative pain.

Active peptic ulcer disease, recent gastrointestinal bleeding or perforation, moderate to severe renal impairment, hypovolemia.

Gastrointestinal y ulceration, bleeding, perfusion, post-operative bleeding, acute and renal failure and liver failure y

Drugs name tramadol Brand name: Tramadol HCL Classification : Opiates and anatgonist

Action

Indication

Contraindication

Adverse Reaction

Nursing Intervention Assess pts pain before and regularly thereafter treatment to monitor drug effectiveness. Monitor for adverse reaction: CNS, dizziness, vertigo, headache, somnolence and anxiety. Monitor intake and output and check for decreasing output may indicate retention. Assess changes in bowel pattern, increase diet bulk and oral fluids to prevent constipation

Centrally acting analgesic not chemically related to opoids but binds to mu-opoid receptors and inhibits reuptake of norepineprhine and serotonin

Moderate to severe pain.

Hypersensitivity. Acute intoxication with alcohol, hypnotics, centrally acting analgesic, opoids or psychotropic agents.

Vasodilatation, y dizziness, vertigo, headache, somnolence, stimulation, anxiety, confusion, coordination disturbances, y euphoria, nervousness, sleep disorder, seizures.

Drugs name

Action

Indication

Contraindication

Adverse Reaction

Nursing Intervention Obtain pt history of infection before and during the therapy and assess response. Assess pt for sign and symptoms of infection Assess allergic reactions. for

Ampicillin Brand name: Ampicillin trihydrate Classification : penicillins

Interfers with cell wall synthesis of susceptible organisms, preventing bacterial multiplication, it also renders the cell wall osmotically unstable and burst due to osmotic pressure. Deactivated by betalactamase, an enzyme produced by resistant bacteria.

Treatment of respiratory tract and soft tissue infections, bacterial meningitis, septicema and gonococcal infections caused by susceptible microorganisms

Hypersensitivity to Thrombophlebitis y penicillins, at injectionsite, cephalosphorinsor dizziness, fatigue, impenem. insomia, reversible hyperactivity, nuerotoxicity. y

Obtain c & s before drug therapy. Monitor function. renal

Drugs name Fluconazole Brand name: flucoral Classification : Antifungals

Action

Indication

Contraindication

Adverse Reaction

Nursing Intervention Assess for sign and symptoms of infectio: obtain c&s baseline and during treatment. Monitor hepatotoxicity: increased AST, ALT, alkaline phosphate, bilirubin; drug will be discontinued if it is occurs. Monitor possible adverse reaction.

Inhibits fungal CYP, an enzyme responsible for fungal steroid synthesis, and weakens fungal cell wall.

Oropharyngeal and esophageal candidiasis; vaginal candidiasis; prevention of candidiasis in bone marrow transplant; cryptococcal meningitis.

Hypersensitivity to fluconazole, other azole antifungals. Co- administration with cisapride and terfenedine.

Headache, seizures, y rash, exfoliative skin disorder, nausea, vomiting, abdominal pain, diarrhea, leukopenia and thrombocytopenia. y

Drugs name Mupirocin Brand name: bactroban Classification : Antibacterials

Action

Indication

Contraindication

Adverse Reaction

Nursing Intervention Document indication for therapy including type, onset, duration and characteristics of symptoms. Obtain c & s before drug therapy. Assess allergic reaction. for

Binds to bacterial isoleucyl transfer RNA synthetase, which results in inhibition of bacterial protein synthesis.

Topical treatment of impetigo, folliculitis, furunculosis, ecthyma, infected dermatoses.

Hypersensitivity. Localized burning, y Not for opthalmic stinging and use. itching.

Monitor for possible drug induced adverde reactions.

Drugs name Metroclopramide Brand name: plasil Classification : Antiemetics

Action

Indication

Contraindication

Adverse Reaction

Nursing Intervention Assess Gi complains: nausea, vomiting, anorexia, constipation. Frequent monitor blood pressure. Assess adverse reaction. for

Dopamine antagonist that acts by increasing receptor sensitivity and response of upper GIT tissues to acetylcholine.

Gastrointestinal motility disturbances. Nausea and vomiting of central and peripheral origin associated with surgery, metabolic disease, malignant disease, infectious diseases and drug induced.

Phaeochromocytoma. Pt in whom increased gastrointestinal motility might be dangerous, presence of GI hemorrhage, mechanical obstruction or perforation.

Sedation, y restlessness, lassitude, fatigue, diarrhea, insomia, headache, dizziness, nausea. y

Monitor for possible drug induced adverde reactions.

Drugs name Omeprazole Brand name: omeprazole Classification : Proton pump inhibitors

Action

Indication

Contraindication

Adverse Reaction

Nursing Intervention Assess other medication that pt taking for effectiveness and interactions. Monitor therapeutic effectiveness and adverse reactions at beginning of therapy and periodically throughout. Assess for GI system Monitor for hepatic enzymes

Supressess gastric secretion by inhibiting hydrogen/potassium ATPase enzyme system in the gastric parietal cell characterized as a gastric acid pump inhibitor since it blocks the final step of acid production.

Short-term treatment of active duodenal ulcer, gastroesophageal reflux diseas, inluding erosive esophagitis and symptomatic GERD.long treatment of pathologic hypersecretory conditions.

Hypersensitivity. Lactation and children. Combination therapy with clarithmycin should not be used in patient with hepatic impairment.

Angina, y tachycardia, bradycardia, palpitation, headache, dizziness, rash and diarrhea. y

Drugs name Prednisone

Action

Indication

Contraindication

Adverse Reaction

Nursing Intervention Assess pts condition before therapy and regularly thereafter to monitor drug effectiveness. Obtain baseline weight, blood pressue and electrolytes levels. Assess adverse reaction. for

Glucocorticoid with minimal mineralocorticoid activity. The antiinflammatory effects Classification : may be due to Adrenocorticosteroid inhibition of prostaglandin hormones synthesis. Brand name: prednisolone

Used as an antiinflammatory of immunosupressant agent. Allergic reaction, selective tissue and muscle disorders, some cases of rheumatoid arthriti.

Patient with osteoporosis, active peptic ulcer, psychoses, systemic fungal infections, acute infections unless effective specifi concurrent therapy can be administers.

Glaucoma with y optic nerve damage, loss of visual acuity delayed wound healing, thromboembolism or fat embolism. y

Monitor BP every 4hrs, pulse notify physician if chest pain occurs.

Drugs name

Action

Indication

Contraindication

Adverse Reaction

Nursing Intervention y Stress importance the Vitamin supplement Teach healthy dietary habits Instruct client not to take folic acid to replace vitamin B12, as it may accelerate hematologic manifestations Sensitivity tests/ intradermal test should be done for those with possible sensitivity Do not mix with other parenteral preparations in same syringe drugs

GENERIC NAME: Coenzyme that Cyanocobalamin RDA for stimulated metabolic cyanocobalamin Vitamin B12 function needed for -Vitamin cell replication, B12 defiency from BRAND NAME: hematopoiesis, inadequate diet, Cyanocobalamin nucleoprotein and subtotal myelin synthesis gastrectomy, other CLASSIFICATION: conditions, disorder Nutritional drugs or disease except malabsorption r/t Vitamins and pernicious anemia Minerals or GI diseas

Patients who are None reported hypersensitive to Vitamin B12 or cobalt and in those with early Lebers disease

y y

Drugs name N-Acetylcysteine

Action

Indication

Contraindication

Adverse Reaction

Nursing Intervention y Assess pretreatment respirations for rate, depth, and rhythm. If bronchospasm occurs, stop the treatment and notify the physician.

Acetylcysteine splits linkage of mucoproteins. It Classification : reduces the Respiratory and viscosity of intratracheal pulmonary inhalant, Mucolytic, secretions, and an Antidote. facilitates removal by coughing, postural drainage, mechanical means. Acetylcysteine protects against acetaminophen overdose-induced liver toxicity.

Acetylcysteine is used in adjunct treatment for abnormally viscid mucous secretions present in acute and chronic bronchopulmonary disease and pulmonary complication of cystic fibrosis, tracheostomy care and in treatment of acetaminophen overdose. It is also used in the prevention of renal damage from dyes given during certain diagnostic tests like CT scan.

Hypersensitivity

Stickiness on face Transient unpleasant odor Increased bronchial secretions, Irritated throat Nauseaand Vomiting Rhinorrhea Skin rash Facial edema Bronchospasm Wheezing

Monitor rate, depth, rhythm, and type of respiration Check sputum for color, consistency and amount. .

VII.

Nursing Care Plan Diagnosis Disturbed body image and low self-esteem related to change in appearance (bulging mass on right neck) and altered structure and function. Planning Implementation Evaluation

Assessment No subjective cues. -

Assessment No subjective cues.

Diagnosis Self care deficit related to pain and body weakness .

Planning

Implementation

Evaluation

Discharge Plan Medication  Antiemetic drug (plasil) for nausea and vomiting side effect of  Mucolytic drugs (N- Acetylcysteine) - to reduce pulmunary secretion or sputum production.  Vitamin B prevention of vitamin B deficiency  Proton pump inhibitor (omeprazole)- decreases of gastric secretion due to the patients is under parental nutrition. Exercise  Walking every morning or encourage the clients to do simple exercise.  Teach the relatives to do to the clients the passive and active Range of motion exercise. Treatment  Comply in medication regimen.  Radiotherapy is the use of high energy x-rays and similar rays (such as electrons) to treat disease. It works by destroying the cancer cell in the treated area.  Avoid exposure to diseases expecially respiratory diseases. Health Teaching  Importance of meeting of nutritional needs. Avoid salted-preservatives foods.  Importance of increasing the immune system, healthy lifestyle and avoid smoking and decrease alcohol intake.  Monitor weight by the relatives.  Advise the relatives not to leave him alone, and assist in activities of daily living.  Importance of proper hygiene and infection control such as handwashing. OPD  Comply with follow-up check-up after a week. Diets  Parental nutrition as ordered by physician.  Foods hign in vitamin C.  1800 cal. 40-60% non-protein.  Increase high fiber diet for enhancement of elimination  Increase vegetables and fruits.  Take atleast 6-8 glass of water to prevent dehydration. Spirituality  Always pray for the guidance of God.  Dont lose hope.  Support network specially the family.

V.1 General Survey Name: PT.A1 General survey Physical presence Stated age vs apparent age y Normal Findings Actual Findings Analysis

The patients stated chronological age should be congruent with the apparent age.

The pt is look like older than his actual age. He lools 6 years older than his real age. Pt.s body is asymetrical; there is obvious deformity in his right neck. Fat is evenly distributed to the body. But there is obvious loss of body fats in the extremities. Limb and trunk should appear proportional to body height and erect Movement is free and effortless

Abormal

General appearance

Patient should exhibit body symmetry, no obvious deformity, and a well appearance

Abormal

Body fat

Body fat should be evenly distributed.

Abormal

Stature

Limbs and trunk should appear proportional to body height; posture should be erect Gait as well as other body movements should be smooth and effortless Normally, there is no apparent odor from patients

Normal

Motor activity

Normal

Body and breath odors

Slightly have foul body odor.

Normal

Psychological presence Dress, grooming, and personal hygiene y Mood and manner

Normally, patients should appear clean and neatly dressed Generally, a patient should be cooperative and pleasant Patient should response to questions and commands easily

Pt. is slightly clean and neatly dressed up Pt. is annoy and like irritated and anxious. Pt. cans response through gestures.

Normal

Abormal

Speech

Normal

Facial expression

Patient should appear awake and alert Breathing should be effortless, without cough or wheezing

Pt.s active

Normal

distress

Breathing is effortless, with productive cough

Abormal

Vital sings Blood pressure Respiratory rate

Normal findings 120/80 mmHg 12-20 cpm

Actual findings 110/80 22

analysis Normal RR slightly increases Due to productive cough Abormal Normal Normal Normal

Pulse rate Temperature Weight Height

60-100 bpm 36.5-36.4 degree celcius

132 36.3 55kg 165cm

Regions Skin y color

Method Inspection

Normal findings --- the skin is a uniform whitish pink or brown, depending on the patients race

Actual findings --skin color is brown

Analysis Normal

bleeding, ecchymosis, and vascularity

-- There are no areas of increased vascularity, ecchymosis or bleeding.

--no increase in vascularity

Normal

lesions

-- no should except

skin lesions be present for feckles,

--with lesion on

Abormal

birthmarks, or moles(nevi),which maybe flat or elevated.

lower extremities -

--normally, the skin is dry with a minimum --Normally dry perspiration. y moisture Palpation

Normal

--Skin is warm y temperature -- Skin surface should be warm. Hand and feet maybe slightly cooler than the rest of the body.

Normal

tenderness

-- skin surface should be nontender.

--nontender

Normal

texture -- skin should normally feel smooth, even, and firm except where there is significant hair growth. --smooth skin Normal

turgor

-- when the skin is released, its should return to its original

--With normal skin turgor (<3sec)

Normal

contour rapidly.

edema -- edema is normally present. not Presence of edema on both upper and lower extremities Abormal

Head y shape of the head

Inspection --the head should be normocephalic and symmetrical. --symmetrical Normal

scalp

--the scalp should be shinny, intact, and without lesions or masses.

--shinny and no lesions or masses

Normal

--the facial features should be symmetrical. y face --the muscles of the neck are symmetrical with the head in a central position. --thyroid tissue moves up with swallowing but often the movement is so small it is not visible on inspection.

Abormal --asymmetrical on right side

neck

--large mass on the both side larger than right side

Abormal

thyroid gland

Difficult of swallowing

Abormal

--lymph nodes should not be visible inflamed. y lymph nodes

--presence of lympnodes in bpth axilla midsternum and illeum --Smooth, non tender, no masses and depression

Abormal

Head

Palpation

--the normal skull is smooth, nontender, and w/o masses or depressions.

Normal

Scalp

--w/o masses.

lesions

or

--No lesion or masses

Normal

Mandible

-the -affected by temporomandibular joint should articulate mass,cant articulate smoothly smoothly and w/o clicking or crepitus.

Abormal

Neck

--the muscle should be symmetrical w/o palpable masses or spasm.

--palpable mass on both side much larger than on right side

Abormal

Thyroid gland

--no enlargement, masses, or tenderness should be noted on palpation.

With masses

Abormal

--lymph nodes should not be palpable in the

--presence of palpable mass neck

healthy adult patient. y Lymph nodes

and axilla,medsternum and illeum

Abormal

Ears Auditory screening y Voice test whisper --the patient should be able to repeat words whispered from a distance of 2 feet. Inspection --the ear should match the flesh color of the rest of the patients skin and should be positioned centrally and in proportion to the head. --the patient should not complain of pain or tenderness during palpation. --no tenderness --able to repeat word, but th pt.hearing is slightly unclear --pinkish to brown Abormal

External ear

Normal

palpation Mouth y Breath Lips --the breath smell fresh. Inspection should

Normal

--foul smell

Abormal

--should be pink and moist with no evidence of lesions or inflammation. --lips should not be flaccid and lesions should not be present.

--dry

Normal

--firm and not soggy

Normal

palpation y Tongue --tongue is in the midline of the mouth. The dorsum tongue be pink, moist, rough w/o lesions. --the color of the oral mucosa on the inside of the check may vary according to race. NA Diffulty to open the mouth widely

NA

Buccal mucosa

Diffulty to open the mouth widely

Gums Teeth

-- the gums have palered stippled surface. -- adult has 32 teeth, w/c should be white w/ smooth edges, in proper alignment, and w/o caries.

NA

Diffulty to open the mouth widely Diffulty to open the mouth widely

NA

Musculoskeletal y Overall appearance --body height and weight should be appropriate for age and gender. -- in the standing position, the torso ad head are upright. --walking is initiated in one smooth, rhythmic fashion. --Ht. and wt. is appropriate in age and gender Normal

Posture

--head is upright

Normal

Gait mobility

and

--gait is normal

Normal

Muscle size and shape Inspection

--Muscle shape may be accentuated in certain body areas but should be symmetrical. There is no involuntary movement. -- joint contour should be somewhat flat in extension, and smooth and rounded in flexion.

--no twitches

Normal

Joint contour and periarticular tissue

--flat in extension --refer to specific sections on joints for the ROM for each joint movement.

Normal

Range of motion

--Normal ROM

Normal

Muscle strength --normal muscle strength allows for complete voluntary range of joint motion against both gravity and moderate to full resistance. Mental status

--normal muscle strength

Normal

Physical appearance and behavior y Posture movement and --the patient should exhibit erect posture, a smooth gait, and symmetrical body movements. -clean and --erect and smooth gait Normal

Dress, grooming

--slightly clean and well well groom fit to her

Normal

and personal hygiene

groomed, and should wear appropriate clothing for age, weather, and socio economic status. --facial expression should be appropriate to the content of the conversation and should be symmetrical. --the patient should be able to produce spontaneous, coherent speech. The speech should be effortless flow with normal inflections.

age and gender

Facial expression

--appropriate to age and topic

Normal

Normal --Can got attention easily

Communication

LA CONSOLACION UNIVERSITY PHILIPPINES CATMON, CITY OF MALOLOS ALLIED MEDICAL SCIENCES

A CASE STUDY
(Nasopharyngeal carcinoma, differentiated Non-keratinizing type 4)

SUBMMITTED TO: Mrs.Jennifer Manlapig,RN (Clinical Instructor)

SUBMITTED BY: Borlongan, Gia Pauline BSN-4 (August 2011)