CERVICAL CANCER

STAGE III
CASE PRESENTATION
(ER)
Introduction:
According to the Filipino cancer registry
annual report, cervical cancer is the second most
common malignancy and is the most common
cause of cancer-related mortality among Filipino
women. Although considered as a preventable
disease, the burden of cervical cancer in the
Philippines remains to be moderately high,
where the cost of nationwide organized cytology
screening has been a significant limitation.
In a country where existing health
infrastructure is not sufficiently developed to
support cytology-based screening program, the
use of alternative screening modalities, such as
visual inspection of the cervix aided by acetic
acid (VIA) with or without magnification, is
currently under evaluation. In addition,
prophylactic Human Papilloma virus (HPV)
vaccination for the prevention of infection and
related disease is being considered as an
additional cervical cancer control strategy.

Introduction:
Cervical cancer is the term for a malignant
neoplasm arising from cells originating in the
cervix uteri. One of the most common symptoms
of cervical cancer is abnormal vaginal bleeding,
but in some cases there may be no obvious
symptoms until the cancer has progressed to an
advanced stage. The Treatment usually consists
of surgery (including local excision) in early
stages, and chemotherapy and/or radiotherapy in
more advanced stages of the disease.

Introduction:
Patient B, 48 years old, a resident of
Sta. Rosa Nueva Ecija was admitted at
Eduardo L. Joson Memorial hospital for
complaints of vaginal bleeding associated
with Dizziness and body weakness on July 10,
2014 , 8:10 am. She said that she was
diagnosed with Stage 3 Cervical Cancer
months ago.

Introduction:
The lack of knowledge and information
about Cervical Cancer is one of the reasons why
we chose this case. Not many Filipino women
know about the disease, that it is preventable and
can be cured when detected at the onset. Cervical
cancer is the 2
nd
most common type of cancer in
women, next to breast cancer. We strongly
believe that this case study will be very helpful in
our career someday as future registered nurses.
And also we want to improve our knowledge in
studying cancer, because of our subject
oncology.

Introduction:
Purpose/ Objective:
Learning Goal Student Centered Client Centered
Skills To be able to perform the
nursing skills learned in school
into real life situation such as
1. Providing safety and
maintaining privacy
2. Proper vital signs
monitoring
3. Giving holistic care and
other necessary nursing
interventions needed for
the patient.
To be able to perform
Independent nursing
skills such as providing
comfort , maintaining
privacy, monitoring, and
keeping the safety of
the patient .

Knowledge To be able to acquire
knowledge regarding cervical
cancer stage 3,its signs and
symptoms, pathophysiology
and course of treatment.
To be able to explain to the
patient his disease according to
his level of understanding.
Attitude To be able to act Professionally
with the supervision of our
clinical instructor.
To be able to give the patient
the holistic care needed
throughout the duty hours .
Biography :
Name: Patient B
Age: 48 years old
Sex: Female
Birthdate: March 10, 1966
Birthplace: Sta. Rosa, Nueva Ecija
Marital Status: Married
Address: Sta. Rosa, Nueva Ecija
Occupation: Housewife
Religion: Roman Catholic
Date and time of consultation: July 10, 2014
Attending Physician: Dr. Sarangaya

Chief Complaint:
The patient experienced vaginal bleeding associated
with dizziness and body weakness.

History of Present Illness:
Three (3) days prior to admission, the patient claimed
that while riding in a tricycle she had a heavy vaginal
bleeding and pain at abdominal pelvic area (pain scale 7/10).
But she refused to be brought to the hospital upon thinking of
financial inadequacy. She went home, took a rest and prayed
that the bleeding would subside.

Biography :
Two (2) days prior to admission, she stated that the
bleeding was no longer that heavy so she did her usual daily
routine. In the afternoon, the bleeding ceased fortunately.
A day prior to admission, Mrs. B experienced weakness
and dizziness while cleaning their house but she ignored it. An
hour prior to admission, she experienced heavy vaginal bleeding
again that made her jeans so stained and wet. She was rushed to
ELJMH (ER).

Past Medical History:
The patients hospitalization was on 1983, she is only 17
years old when she had her 1
st
pregnancy with normal delivery
(her other 2 pregnancies was done by the hilot) she delivered a
normal baby .

Biography :
Her 2nd hospitalization was on April 21, 2014,
because of heavy vaginal bleeding and she stayed at the
hospital (ELJMH) for 5 days.

She was submitted for an ultrasound with a negative
result. On April 26, 2014 the date of her discharge, the
bleeding occurred again so the physician decided to submit
her for a biopsy exam (to determine of metastasis) thus
postponed her way home. Later, she was diagnosed to have a
cervical cancer stage III through the biopsy result.

Biography :
Supposedly, the patient will undergo an operation but
due to some reasons the physician advised that chemotherapy
and radiation therapy would be the best intervention for her
condition. Unfortunately Pt. B is not financially stable for the
said therapy so she was discharged last May 06, 2014.
Biography :
Past Surgical History:
The patient has not yet undergone in any surgical
procedure.
Allergies/ Medications:
She claimed the she had no allergies.
Smoking, Alcohol, Substance Abuse :
Non smoker/ alcoholic
Social/ Work History:
Mrs. B has a good relationship with her family. She is a
good wife and mother to her children. The patient claimed that she
believes in quack doctors (albularyos) but she prefers to
seek medical care. Mrs. B worked as a factory worker (exporting
sea foods company) almost 20 years ago, before she was being
diagnosed of cervical cancer.

Biography :
Family History:
The patient claimed that she doesnt know about the
causes of her grandparents death both paternal and maternal
side. Some of her relatives are alcoholics. This includes her
father who died of suicide while drunk at the age of 69 years
old. Her mother died of cervical cancer at the age of 62 years
old. Her third cousin (paternal side) also died of cervical
cancer. Another cousin is suffering from breast cancer until
now.

Biography :
Review Of System:
Pathophysiology:
Non-Modifiable Factors
Age (48 years old)
Sex (exclusively for female)
Heredity (history of cervical CA)
Modifiable Factors
Sexual partner who had multiple sexual partner
(HPV exposure)
Low economic status
Diet and lifestyle
Multiple Pregnancies (7 and above delivered)
Somatic Mutation in
DNA or Gene
Altered genetic structure and
autoimmune response
Activated oncogene or deactivate
cell tumor suppressor gene
Malignant transformation of
lymphoid stem cells
Formation of clones or uncontrolled
proliferation lymphocytes
Cervix cells dysplasia after lymphoblastic cell event
Acquisition of invasive characteristics
Through sexual intercourse: HPV penetrates
squamous columnar epithelial cervix cells
Tumor cells engulf lymphocytes
Virus transcripts stroma
Activation of oncogenic cell
growth factor
Host cells put up tissue barrier
Altered production of normal
cells
Hematology
Lab Result:
Increased
WBC 11.2
Hematology
Lab Result:
Decreased
RBC 2.43
10^12/L
S/Sx:
Infection
Fatigue
Pallor
Increased RR: 25cpm

Tumor cells attach in the cervix
cells
Spread and invades distant tissues
(vagina)
Autoimmune inhibition
progression (malignant)
Asymptomatic tumor growth
Cervical Cancer Stage III
Diagnostic
Test:
Cervical
Biopsy
Pathophysiology:
Affection of the surrounding
tissues of the cervix along the
vagina
Necrosis and infection of
the tumor
Gain access to pelvic lymph
nodes
S/Sx:
Vaginal Bleeding
Dark and Foul
Odor

Hematology
Lab Result:
Decreased
HGB 2.78
10^12/L
Increased tumor growth
Hypermetabolic activity
Fundus
Irritation of nerve
endings
S/Sx:
Excruciating pain
in back and legs

Weight loss:
45 40 kl. of
the pt. weight.
Pressure on the
surrounding tissue
PROGNOSIS
With Medical Management:
Hysterectomy
Chemotherapy
Radiation Therapy
Without Medical Management:
Tumor Metastasis may occur
Pathophysiology:
Good Prognosis
IVF Replacement
Follow prescribed
medication by the
physician
Poor Prognosis
Multi-organ failure or
complication and Sepsis
Possible for recovery
35 40% Rate of
Survival; about 5 yrs. in
Cervical CA Stage III
Coma
Death
LEGENDS:
RISK FACTORS
PATHOLOGY
MANAGEMENT/DIAGNOSTIC TEST
MANIFESTAT
IONS
LABORAT
ORY
TEST/RES
ULT
Pathophysiology:
I. Vital Signs:

Temperature

Pulse Rate

Respiratory Rate

Blood Pressure
Actual Findings:

37 degree Celsius

88 beats per minute

22 cycles per minute

100/80 mmHg

II. Level of Consciousness Conscious and Coherent
PHYSICAL ASSESSMENT
III. BODY PARTS NORMAL FINDINGS ACTUAL FINDINGS REMARKS
GENERAL
APPEARANCE
With normal weight,
afebrile, proportionality
and symmetry
Thin in appearance.
Afebrile,
The body parts are
proportional to each
other.
Her thin in appearance is due
to her aging in which there is
a decreased in the distribution
of fats within the body. Her
disease also contributes in his
thin appearance
SKIN The color depends on
race, ethnic background,
complexion, sun
exposure, and
pigmentation tendencies.
Pallor noted.
Cool and clammy to touch.
Good skin turgor in both
upper and lower extremities;

the skin returns to its
previousstate immediately
after being tented.


Due to anemia
A. EYES and VISION Normal vision of 20/20,

Pale conjunctiva.

Able to read words at a
distance of 18-20 inches.
(+) Pupils Equal Round and
Reactive to Light
Accommodation
(PERRLA).

Pale conjunctiva is due to
anemia
PHYSICAL ASSESSMENT
MOUTH Lips are moist and pink,
no masses, gums are pink
and smooth, The tongue
is midline and without
any hoarseness of voice.
Dry and pale lips noted upon
inspection.

Incomplete teeth noted.
Tongue is able to move freely
and able to swallow foods
Good oral hygiene


Due to anemia
ABDOMEN The contour of the
abdomen is usually flat
and rounded, the skin
surface is smooth, and
even with homogenous
color and good skin turgor.
Presence of striae gravidarum
noted.

Audible bowel sound upon
auscultation.

Abdominal dullness upon
percussion.

Presence of solid rounded mass
noted upon palpation (left
inguinal region)
.
Abdominal pain (pain scale of
7/10) complained.



Due to previous pregnancy

Normal


normal


Due to presence of tumor


Due to severe vaginal bleeding
and due to her condition /UTI
(common signs of Cervical
cancer)
PHYSICAL ASSESSMENT
Course of Treatment:
COURSE IN ER

7-10-14 Blotter taken (V/S, Chief complain, Personal data taken)
Conduct interview/observation
IVF D5LRS IL X 5 hours (inserted by NOD)
Given tranexamic Acid 1amp IV (for heavy vaginal bleeding)
Consent for admission
Laboratory co-management: For CBC with APC, UA, BUN,
Crea, Na, K, Ca, Blood typing
Admit to room under the service of Dr. Sarangaya
Transferred to ward via wheelchair
Endorsed
PHARMACOLOGIC TREATMENT

Date Generic/
Trade name
Dosage/
Frequency/
Route
Classification indication contraindication side effects Nursing
responsibilities
7-10-2014 Tranexamic
Acid
500 mg slowIVTT Allergic reaction to
the drug or
hypersensitivity

Presence of blood
clots (e.g., in the leg,
lung, eye, brain), have
a history of blood
clots, orare at risk for
blood clots

Treating heavy
menstrual bleeding

Hemorrhage

Allergic reaction to the
drug or hypersensitivity
Presence of blood clots
(e.g., in the leg, lung,
eye, brain), have a
history of blood clots, or
are at risk for blood clots

Nausea and
vomiting
Anorexia
Headache may
appear
Impaired renal
insufficiency

1) Instruct the
patient to take
the medication
using the rights
of medication
administration
such as right
time, right dose,
right route
2) Unusual change in
bleeding pattern
should be
immediately
reported to the
physician.
3) For women who
are taking
Tranexamic acid to
control heavy
bleeding, the
medicationshould
only be taken
during the
menstrual period.
4) The medication
can be taken with
or without meals.

ASSESSMENT NURSING
DIAGNOSIS
SCIENTIFIC
EXPLANATION
PLANNING INTERVENTION RATIONALE EVALUATION
Subjective Cue:
Ang sakit ng
puson ko, as
verbalized by the
patient. Pain scale
8/10.

Objective Cues:
Guarding/pr
otecting the
affected site
Facial
grimace
noted
Restlessness
noted
Diaphoretic
noted
V/S noted
o Temp.: 36.3
C;
o HR: 80 bpm;
o RR: 25 cpm;
o BP: 100/70
mmHg

Chronic pain
related to pressure
in the left inguinal
region secondary to
cervical cancer as
evidenced by that
patients pain scale
of 8 out of 10,
facial grimace,
guarding the
affected site and
her verbalization.

Chronic pain
persists over a
longer period of
time than acute pain
and is resistant to
most medical
treatments. It often
causes severe
problems for
patients.

Within 35 mins. of
giving appropriate
nursing
interventions, patient
will be able to
verbalize reduction
of pain from 8/10 to
0/10.
Independent
Provided
cutaneous
stimulation; e.g.,
heat/cold,
massage.
Provided non-
pharmacologic
comfort
measures and
diversional
activities.
Evaluate pain
relief/ control at
regular intervals.
Adjust
medication
regimen as
necessary.
Assessed for
referred pain as
appropriate.


Noted and
investigated
changes from
previous reports.


Provided
comfort
measures and
quiet
environment.

May decrease
inflammation,
muscle spasms,
reducing
associated pain.
Promotes
relaxation and
helps refocus
attention.

Goal is
maximum pain
control with
minimum
interference with
ADLs.


To help
determine the
possibility of
underlying
condition.
To rule out
worsening of
underlying
condition or
development of
complications.
To promote non-
pharmacological
pain
management.
After 35 mins. of
giving appropriate
nursing interventions,
goal partially met.
Patient verbalized
reduction of pain from
8/10 to 5/10.
NURSING CARE PLAN

ASSESSMENT NURSING
DIAGNOSIS
SCIENTIFIC
EXPLANATION
PLANNING INTERVENTION RATIONALE EVALUATION
Dependent
Administered
analgesic as
indicated by the
physician.

A wide range of
analgesics and
associated
agents may be
employed
around the clock
to manage the
pain.
NURSING CARE PLAN
ASSESSMENT NURSING
DIAGNOSIS
SCIENTIFIC
EXPLANATION
PLANNING INTERVENTION RATIONALE EVALUATION
Subjective Cue:
Naiiyak na nga
ako kasi dinurugo
pa rin ako
hanggang
ngayon, as
verbalized by the
patient.

Objective Cues:
Weight loss from
45 to 40 kl.
Pallor noted
Feeling of
dizziness noted
Irritability noted
Dry skin mucus
membrane noted
V/S noted
oTemp.: 36.3 C;
oHR: 80 bpm;
oRR: 25 cpm;
oBP: 100/70
mmHg

Fluid volume
deficit related to
cervical bleeding
as evidenced by
weight loss from
45 to 40 kl, pallor,
feeling of
dizziness,
irritability and
dry skin mucus
membrane .
Fluid
volume deficit is a
condition when fluid
loss exceeds intake
and electrolytes in
the human body
become unbalanced.
Cells do not have
enough water to
function properly
when a fluid volume
deficit develops
from blood
loss, vomiting or
diarrhea. Excessive
sweating and high
fever can also lead to
a deficit as a result
of dehydration.
Within 3 days of
giving appropriate
nursing
interventions,
patient will be
able to maintain
fluid volume at a
functional level as
evidenced by
moist mucus
membrane.

Independent
Established rapport
to the patient.
Assessed V/S.

Encouraged fluid
intake to 3000 ml a
day, unless
contraindicated.




Recommended
restriction of caffeine.
Evaluated CFAC
(Color, Frequency,
Amount, and
Consistency) of urine,
e.g. bright red with
red clots.
Regulated IVF level
(D5LR) accurately.

Dependent
Infused PRBC with
IVF as ordered by the
physician.

To gain trust and
cooperation.

To obtain baseline
data.
It flushes
kidneys/bladder of
bacteria and debris but
may result in water
intoxication/fluid
overload if not
monitored closely.
To reduce effects of
dieresis.

Usually indicates
arterial bleeding that
required aggressive
therapy.



Necessary for fluid
volume replacement.


Useful in evaluating
blood losses/
replacement needs.
After 3 days of
giving
appropriate
nursing
interventions,
goal partially
met. Patient
was able to
slightly
maintained
fluid volume
balance.
NURSING CARE PLAN
ASSESSMENT NURSING
DIAGNOSIS
SCIENTIFIC
EXPLANATION
PLANNING INTERVENTION RATIONALE EVALUATION
Subjective Cue:
Hindi maganda
ang pakiramdam
ko ngayon, as
verbalized by the
patient.

Objective Cues:
Weakness noted
Restlessness noted
Capillary Refill
Test: < 3 seconds
V/S noted
oTemp.: 36.3 C;
oHR: 80 bpm;
oRR: 25 cpm;
oBP: 100/70
mmHg

Ineffective tissue
perfusion related to
interruption of
blood flow as
manifested by left
inguinal region
chronic tenderness.
Inadequate tissue
perfusion can be a
diagnosis, a sign and
a symptom that one or
more organs of the
body are beginning to
fail due to a lack of
oxygenated blood
either reaching an
organ or fully
circulating through an
organ or body system.
Within 3 days of
giving appropriate
nursing
interventions,
patient will be able
to verbalize from
being not feeling to
good condition.
Independent
Established
rapport.
Monitored and
recorded V/S.
Monitored and
recorded intake and
output.

Advised the patient
to have quiet
atmosphere/environm
ent.
Compared skin
temperature and color
with other limb when
assessing extremity
circulation.
Measured capillary
refill test.


Assessed motor and
sensory function


Dependent
Administered IVF
(D5LR) as prescribed
by the physician.

To gain trust and
cooperation.
To establish baseline
data.
To determine fluid
volume for oxygen
transportation and
circulation.
Quiet environment
conducive to rest
alleviates stress.

Helps differentiate
type of underlying
problem.



To determine
adequacy of systemic
circulation.
Loss of sensation,
numbness or any
changes that can
indicate limb ischemia.

Replacement of
blood losses maintains
circulating volume and
tissue perfusion.
After 3 days of
giving
appropriate
nursing
interventions,
goal partially
met. Patient
verbalized that
she is in a bit
of good
condition.
NURSING CARE PLAN
Discharge Planning
Medication:
The possible home meds to patient are as follows:
Analgesic (for pain)
Ampicillin
Multivitamins w/ iron
Instruct the patient to take the medication using the rights of medication
administration such as the right time, right dose, right route.

Exercise:
Instructed patient to provide a peaceful relaxing, comfortable and well
ventilated room.
Instructed patient to provide a stress free environment.
Instructed patient to follow the prescribed meal plan.
Instructed to provide clean environment to prevent lodging of infectious
microorganisms.

Discharge Planning
Treatment:
Discussed on the importance of strict adherence to medication regimen to
ensure complete healing.
Instructed patient to understand and follow discharge instruction religiously
and accurately.
Instructed patient to follow proper instruction on medication prescribed by the
physician

Health teachings:
Explain the importance of good hygiene
Explain the take home medications and its possible side effects.
Emphasize adequate sleep and rest pattern
Verbalize the importance of taking foods rich in vitamins

Discharge Planning
Out- Patient:
Instruct the patient and the relative to have a follow up check- up for one to
two weeks after discharge or depending on the Physicians decision.

Diet:
Advised patient to avoid raw foods.
Encouraged the patient to eat green leafy vegetables.

Spiritual:
Patient must go to church and pray regularly together with her family. Never
forget to thank God for all the blessings she and her family has been
receiving.
Patient must find time with his family members and friends and share the
good news written in the bible.
So must pray for the health of the patient.