Kathmandu Model Hospital

School Of Nursing
Swoyambhu, Kathmandu.

Case study on Carcinoma of Skin

On Bhaktapur Cancer Hospital

For the partial fulfillment of the requirement of Post Basic

Bachelor of Nursing Degree in Purvanchal University

Submitted To : Submitted By:

Faculty of PBBN 3rd year Ursulla Maharjan
RollNo :18
PBBN 3RD YEAR
Batch :2073/074

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TABLE OF CONTENT

Pre face
1. Acknowledgement ……………………………………………………...4
2. Background …………………………………………………………......5
3. Case selection ……………………………………………......................5
4. Objectives………………………………………………………………..6
Part I
5. Biographical date of patient…………………………………………..….7
6. Chief complain……………………………………………………….......8
7. Health history of Patients …………………………..................................8
8. Family Tree…………………………………………………………........11
9. Physical examination………………………………………….…………12
10. Development task of young adult………………………………............15
Part II (Disease profile)
11. Definition of carcinoma of lung ..…..……………..................................16
12. Classification.............................................................................................17

13.Causes…………………………………………………………………….19
14. Pathophysiology…………………………..………………......................20
15. Clinical feature……………………………………………......................21
16. Diagnosis …………………………………….………………................23
18. Investigation done in my patient………………..……………….............23
19. Management and treatment………………………………….…………..24
20. Nursing Management……….…………………………………………..25
21. complication …..…………………………………….............................26
Part III
22. Applying Nightingale theory……………………………………………27
23. Nursing care plan………………………………………………………..29

24. Drugs used in my patient………………………………………………..36

25. Daily progress and management of my case……………………............42
26. Stress management……………………………………….……………..43
27. Summary of the case study…………………..……………………47
28. Learning from the case study……………………………………...48
29. Reference……………………………………………………...........49

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ACKNOWLEDGEMENT

This hospital based case report on “Carcinoma of skin" has been completed within duty
period in Bhaktapur Cancer Hospital. The fact is that without the help of some intellectual
giants and wellwishers, I never could have completed this case study. I would like to express
my sincere thanks and appreciation to all those people whose voluntary efforts continue to
confront the received wisdom.

First of all I would like to thank college for the syllabus and gave us an golden opportunity to
do case study, our campus chief madam; Sanu Tuladhar madam, and respected faculty
teachers Ms Gayatri Maharjan, Ms Gyanu Maharjan, Ms Nardevi Bariya and Ms Ramila
Maharjan for their continuous supervision, direction, guidance, support and encouragement
throughout the case study period.

I would like to express my heartfelt gratitude to the director, matron, ward in-charge of the
Bhaktapur Cancer Hospital for granting me permission to conduct case study and all the
staffs concerned to the care of my patients for their help and kind cooperation, without
whom, this case study would not have been completed.

My sincere thanks go to my colleagues and seniors for their valuable suggestions and help
and of course to the library staffs of KAMHSON for providing me necessary books and
materials.
Not forgetting, my genuine gratitude is offered to the patient and his family for providing me
valuable information, time, cooperation that allowed me to successfully study the case, thus
providing me a huge concept on “Carcinoma of skin “disease as a whole.

Last but not the least I would like to thank heartily to my all family members of KAMHSON
for their constant help while preparing this case study.

Finally, I would like to thank to all my forgotten and unforgotten friends and related person
who had helped me directly and indirectly so far.

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BACKGROUND

As a partial fulfilment of Post Basic Bachelor of Nursing curriculum of Purbanchal

University under practicum of Oncology Nursing, we were supposed to do 2 weeks practicum
at Bhaktapur Cancer Hospital where we, individually were supposed to do a detailed case
study of a patient.

The case study report on ‘Carcinoma of Skin ’ is prepared as an overall fulfilment of

PBBN curriculum. So, I feel it is important to gain new knowledge.

Cancer becomes the increasing burden as a non-communicable disease in Nepal. New and
advanced technology has proven that cancer can be cured if detected early and a cancer
patient can have a good quality of life.

This case study will be helpful in identify the risk factors, causes and manage them on
time and work approximately with community which could contribute in reducing mortality
and morbidity.

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CASE SELECTION

I select ‘Carcinoma of Skin’ for my case study because I have chosen to know the effect of it.
I have to learn about the detail case study of Carcinoma of Skin i.e. type, sign and symptom,
pathophysiology and treatment and management and to reduce the mortality and morbidity.

I have selected the case of CARCINOMA OF SKIN because :

According to some of the major statistics which describe skin cancer in the United States.

 Skin cancer and melanoma account for about 50 percent of all cancers diagnosed.
 Skin cancer is one of the more preventable types of cancer.
 More than 90 percent of skin cancer is caused by excessive exposure to the sun.
 Each hour, one person dies from skin cancer. It is not something to be dismissed as a
health risk.

Given the final statistics here, skin cancer can't be dismissed as being a minor risk. People
can, and do, die from the disease. And for those who are survivors, treatment can be painful
and disfiguring.

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OBJECTIVE OF CASE STUDY

GENERAL OBJECTIVES

General objectives of this study and suggested by the curriculum is to gain the compressive
knowledge about the disease pattern and also be able to gain practical exercise giving holistic
patient care of the patient in the disease condition and to educate patient and their relatives
and enable them to educate others about the care of the CARCINOMA OF SKIN.

SPECIFIC OBJECTIVES

 Establish rapport and gain the trust and co-operation of the patient and immediate
family members.

 Gather factual health assessment of the patient. Perform proper assessment of the
patient.

 To gain new facts and ideas about the disease.

 To gain better and clearer understanding on the nature, course, physical and
emotional changes and signs and symptoms relevant to this disease.

 To disseminate information to the patient as well as his relative about the illness and
how to care for the patient.

 To be able to formulate related nursing diagnosis from the patients health data and to
the current problems the patient experiences and to come out with different nursing
interventions effective for the patient to improve and progress on the most possible
time.

 Set realistic objectives of care.

 To provide individualized quality care to the patient by using a holistic nursing care
and problem solving approach.

 To study, document and present a case study`s report on CARCINOMA OF SKIN

disease in front of respected teachers, staffs and friends.

 To take feedback from all in positive way.

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DEMOGRAPHIC DATA

Name :Prem Malla

Age/sex -50yrs/Female

Education :Literate

Economic status :Middle class

Ward :Chemo ward

Bed no :110

Inpatient no :89674

Religion :Hindu

Nationality :Nepali

Occupation :Agriculture

Marital status :Married

Address : Baglung

Diagnosis : Squamous cell carcinoma of skin

Date of admission :2076/01/17

Consultant Dr :Dr. Suresh

CHIEF COMPLAINT: Pt has been referred fom Bir hospital for radiation therapy.

HISTORY OF PRESENT ILLNESS

A history of mass over the right thigh , and patient also had swelling over the right thigh
which grew in size and there was discharge too. Patient went to nearby hospital where
primary management was done . As the wound didn’t heal he went to TUTH for further
treatment , where excision biopsy from inguinal lymph node of right side was done and found
out about the squamous cell carcinoma of skin. Thereafter he was referred to Bir hospital for
further treatment where he received 2 cycle adjuvant chemo. Then he was referred to
Bhaktapur cancer hospital for radiation therapy.

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HISTORY OF PAST ILLNESS

He had burn over his left leg many years back and had under gone surgery for that .

PERSONAL HISTORY

Alcohol/smoking: He used to smoke one packet a day and has quitted since last 2-3years.

Eating habit: He used to have regular 3meal a day and was a non veg.

Food allergies: He did’t have any known food allergies till now.

Rest and sleep pattern: He used to have a good 7-8 hours sleep.

Elimination habit: He had regular bowel and bladder habit.

Recreational habit:He used to listen to the radio most often in free time.

Mental health:He has stable mental health given that he has not suffered from any sort of
mental illness.

FAMILY HISTORY
There was no any significant h/o diseases in the family .

SOCIOECONOMIC HISTORY
Middle socioeconomic condition.

DRUG ALLERGY HISTORY

No known drug allergies.

HEALTH BELIEF
He believed in both traditional and modern health practices.

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FAMILY TREE

PATERNAL MATERNAL

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GENERAL PHYSICAL EXAMINATION

PHYSICAL EXAMINATION

 Develop(obtain baseline data) and the data base from which subsequent phases of the
nursing process can evolve
 To identify and manage a variety of patient`s problems(actual and potential).
 To maintain holistic care approach.
 Evaluate the effectiveness of the nursing care.
 Maintain effective and good interpersonal relationship.
 Make clinical judgments.
His general condition is fair. He is well oriented to time, place and person. I had
examined him from head to toe in cephalocaudal approach by using four methods ;
inspection, palpation, percussion and auscultation in a systemic way.
Vital signs and weight/height
Temperature: 980f
Pulse: 82b/m
Respiration:24b/m
Blood Pressure: 130/70 mm of Hg
Height:5feet 11inches
Weight:69kg

GENERAL APPEARANCES

General condition: Fair

General state of Health: Cheerful and active
Nutritional condition: Well nourished
Gait: limpy due to the wound on the right leg
Personal hygiene: ill hygiene, and ill groomed
Behaviour: Appropriate reaction to the situation

SYSTEMIC PHYSICAL EXAMINATION:

A. INTEGUMENTARY SYSTEM
SKIN
Inspection:
Fair complexion without cyanosis, rashes any patches or any lesion. No bleeding,
laceration, bruising or swelling over his body except the wound on the rt thigh..

Palpation:
Warm and soft skin with even temperature all over his body, no tenderness over his back.
Has good sensation and motor functions of both upper and lower extremities

B. LYMPH NODES
Enlarged lymph nodes over the right thigh and left inguinal region.

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 C. HEAD AND FACE
Inspection:
Well distributed, clean, saving of hair present. No any dandruff.

Palpation:
No swelling, lump or injury over scalp or forehead .There was no tenderness of the scalp.
No tenderness over the sinuses.

EYES:

 Both eyes were symmetrical in shape, size and location with equal movements.
 No bulging of eyes.
 No redness or discharge from the eyes.
 No pain or complain of any visual problems.
Eye Brows: symmetrical, well distributed. No eye brows fall.
Eye Lids: No redness, edema, lesion or dropping.
Eye Lashes: outward and upward curled.
Conjunctiva: transparent
Pupil: round and uniform in shape and size. Constrict in bright light and dilate in dim
light.
Lens: transparent
Eye Movements: normal
No any signs of anemia or jaundice. Extra ocular eye movement is normal. Peripheral
vision is intact with no any visual disturbances.

EARS:
Inspection:

 Normal shape, size and symmetry.

 Top of pinna meets eyes at the line of outer canthus of the ear.
 No lump, lesion or discharge.
 No redness, mass or foreign body present on the external auditory canal.

Palpation:
No any tenderness or swelling present on the mastoid bone.
Hearing activity: normal and can hear the sound of normal conversation.
NOSE:

 Medially located. Nostrils uniform in size& do not flare on respiration. Nasal

septum is not deviated.
 No lesion, redness, tenderness or blockage of nasal pathways.
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  Intact smelling sense.
MOUTH AND THROAT:
Lips: Looks dry and dehydrated. No cracks or angular stomatitis.
Gums: Pink without bleeding or swelling.
Teeth: 27 teeth are present in total number. Dental caries present .
Tongue: Moist, no tongue tie present. Can identify the sense of taste. No signs of injury.
But dryness of tongue.
Palate and uvula: Dry and pink. No any signs of injury in palate and uvula located in
midline of the throat.
Throat: Tonsils are not inflamed.

D. NECK
Cannot move neck in all the directions due to surgery.
No visible or palpable thyroid, salivary glands and lymph nodes.
Dressing over the submandibular present.

E. CHEST
RESPIRATORY SYSTEM
Subjective data:
Chest pain: Absent
Dyspnea: ocassional (with activities)
Clubbing of fingers: Absent
Cyanosis: Absent
Inspection:
 Trachea and sternum are located in a midline.
 Normal in shape and symmetry.
 Equal expansion of chest bilaterally during inspiration and expiration.

Palpation:

 No tenderness, lumps or depression present along the ribs.

Percussion:

 Resonant sound heard over the lungs.

 Dull sound over the heart.

Auscultation:

 Clear breathe sounds present over all areas of lungs with no added breathe
sounds (wheezes, crepitation, rhonchus).

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 CARDIOVACULAR SYSTEM


Regular heart beat with rate of 82/min.

S1S2 (lub/ dup) present with no other added sounds or heart murmer.

Apex beat heart on fifth intercostals space mid clavicular line.

Peripheral pulses (brachial, radial, femoral, posterior tibial and dorsalis pedis)
were palpable.
 Apex beat is symmetrical with other peripheral pulses i.e. 86 per minute
 Capillary refill time is less than 2 sec.
 Palms of hands appear pink.
F. ABDOMEN
Inspection:
 Cylindrical in shape.
 No scars, injury or visible blood vessels.

GASTROINTESTINAL SYSTEM

 Is on normal diet and takes food regularly

 Had normal bowel and bladder habit
 Nausea, vomiting, heart burn was absent.
 No signs of hernia.
 Umbilicus located in midline without any redness, discharge or swelling.

Auscultation:

 Gurgling peristalsis movement audible on all the four quadrants within 2 to 5

seconds.

Palpation:

 No any pain, tenderness or other palpable mass was present over entire
abdomen.
 Liver: no tenderness or palpable per abdomen.
 Spleen: no tenderness or palpable per abdomen.

Percussion:

 Dull sound over right and left hypochondriac and umbilical region.
 Tympanic sound present on other region.
G. GENITOURINARY SYSTEM
 No history of painful or burning micturation.
 Costo-vertebral tenderness absent.

H. BACK
Inspection:
 No any deformity on the back is seen (Kyphosis, scoliosis or lordosis).
 No any Swelling present over lumbar region
Palpation:
 Vocal fremitus present.
 Bilateral equal expansion of back during respiration.
 No any tenderness present

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 Percussion:

 Resonance sound present over the back.

Auscultation:

 Bilateral clear breathe sound heard over the back .

I. UPPER AND LOWER EXTREMITIES

 Both right extremities are of equal size, shape and symmetrical without any
deformity.
 Leg movement was decreased due to wound on the right leg
 No redness, swelling or any tenderness.
 Capillary refill: less than 2 sec
 Color of nail bed: pink
 Peripheral pulses: present
 Normal temperature of extremities on palpation.
J. NEUROMUSCULAR SYSTEM
 Level of consciousness: conscious and oriented to time, place and person
 Equal strength & co-ordination on both sides of extremities.
 Sensory and motor functions are intact up to the level of all .
 Bicep and triceps, brachioradialis, abdominal reflex, knee-jerk, Achilles and
plantar reflexes are present. Patient shows normal response to stimuli.

ABNORMALITY IN PHYSICAL EXAMINATION

 Limpy due to the wound on the rt leg.

 Ill hygiene, and Ill groomed.
 Enlarged lymph nodes over the right thigh and left inguinal region.
 Ocassional dyspnoea (with activities)
 Leg movement was decreased due to wound on the right leg

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DEVELOPMENTAL TASK
Developmental task is a growth responsibility that arises at a certain time in this course of
development, successful achievement of which leads to satisfaction and success with later
task. Failure leads to unhappiness, disapproved by society and difficulty with later
development tasks and functions.

Middle adult starts at the age of 40-60 years. This is a period of physiological changes that
are gradual and inevitable, although physical growth has stopped, he continues to mature
emotionally. In this period he has obtained personal achievement and socio economic
stability. This is a time helping aging parents though the later years of life. The middle age
adult uses his leisure time in creative work and gets satisfaction from his own work. This is
the time when a person prepares for retirement

According to Erik Erikson(1963) developmental theory, middle age is the period of

generatively versus stagnation. It is the seventh stage of life and involves willingness to care
for and guide other. For example caring for his/her own children. The children of his/her
relatives and guide them. If the middle aged adult fails to achieve general activity is has
causes stagnation, this means more self concern and destructive attitude towered children and
community.

HAVIGHURST’S DEVELOPMENTAL TASKS FOR MIDDLE AGE

According to the book According to patient

1) Achieving adult civic and social He used to get participate in social cause and
responsibility . issues.

2) Establishing and maintaining an economic He used to earn his living by engaging in

standard of living . agriculture.

3) Assisting teen-age children to become He used to fulfill his childrens wishes

responsible and happy adults. whichever way he could.

4) Developing adult leisure, time activities He used to listen to the radio in leisure time.

5) Relating oneself to one’s spouse as a He seems to care for his wife.

person .
He had acceptance of his physiological
6) Accepting and adjusting to the changes .
physiological changes of middle age
He used to take a good look after of his old
7) Adjusting to ageing parents. mother.

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ANATOMY AND PHYSIOLOGY OF SKIN

Introduction

The skin is a complex organ system that has many important functions. The skin functions as
a protective barrier against external organisms, maintains temperature control, senses our
surroundings, eliminates wastes, and synthesizes Vitamin D.

Function of Skin

Skin is much more than an outer covering. It functions to maintain the body in homeostasis
despite daily external assaults .Skin also stores fat and water, and plays a role in immunity
from disease.

Some of the skin’s major protective functions are :

Thermoregulation

The skin acts to maintain temperature control by secreting sweat from our sudoriferous
(sweat) glands. This sweat helps to lower body temperature.

Protection

The skin is the first layer of protection when it comes to invading organisms. It also helps
protect against excessive water loss, chemicals and other harmful substances, and ultraviolet
radiation.

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Sensation

The skin has many nerve endings that send signals to the brain to convey sensations such as
touch, pain, pressure, and temperature.

Excretion

The skin helps rid the body of wastes. It does this via perspiration. Perspiration secretes
water, salt, and a small amount of organic chemicals.

Synthesis of Vitamin D

Vitamin D is required to allow the body to absorb calcium and phosphorus. When the skin is
exposed to ultraviolet light or sunlight, it converts a vitamin D precursor to vitamin D via the
liver and kidneys.

Structure of Skin

The skin is the heaviest single organ in the body .Skin varies in thickness, color, and texture.
There are two major types:

 Thick and hairless, found on the palms and soles of feet in areas that are heavily used.

 Thin and hairy, found over most of the body.

Layers of Skin

The skin has three layers with different thickness, strength and function:

Epidermis: Thin outer layer

Dermis: Thick inner layer

Hypodermis or subcutis: A fatty layer of subcutaneous tissue

Epidermis

The epidermis is the top layer of skin and serves several functions, including protecting the
interior of our body from the environment. Cells in this layer include the following, which
give rise to the most common skin cancers—squamous cell carcinoma, basal cell carcinoma,
and melanoma:

 Squamous cells lie just below the outer surface of the skin.
 Basal cells lie beneath the squamous layer and produce new skin cells.
 Melanocytes are located in the basal cell layer of the skin and produce melanin, the pigment
that gives skin its color.

Dermis

The dermis is the middle layer of skin made up of collagen and elastin. It contains hair
follicles, oil-producing glands (sebaceous glands), nerves, and blood vessels.

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Subcutaneous Tissues

The subcutaneous tissue contains fat, connective tissue, and larger blood vessels; the amount
of this tissue varies depending on a person's weight.

CARCINOMA OF SKIN

Skin cancer is the most common type of cancer diagnosed in the United States and can be
broken down into squamous cell cancers, basal cell cancers, and melanomas, as well as some
less common cancers. Symptoms may include a sore that doesn't heal, a new spot on the skin,
or a mole that is changing.

When doctors suspect a skin cancer during an exam, a biopsy is needed to make the
diagnosis. Treatment options depend on the type and stage, with surgery to remove cancer
being the most common approach. With melanomas and advanced squamous cell carcinomas,
other treatments such as immunotherapy, chemotherapy, or radiation may be needed.

EPIDEMIOLOGY

The incidence of skin cancer crosses every socioeconomic group and demographic region,
includes every ethnicity, and covers the entire life span. The American Cancer Society (ACS)
predicted an excess of 1.1 million new cases of cutaneous malignancy ending in 11,200
deaths in 2008. Actual figures are not available because reporting nonmelanoma skin cancer
to the cancer registry is not required. The ACS predicted 62,480 new melanoma cases
diagnosed in the United States in 2008, resulting in 8420 deaths. The cost of treating skin
cancer in the United States is estimated to be more than $2.9 billion annually. Skin cancer is
also a growing global problem. The Netherlands is predicting an 80% increase in the total
number of skin cancer patients by the year 2015. Canadian researchers have demonstrated an
overall lifetime risk for diagnosis of a nonmelamoma skin cancer increased 2 to 3 times in the
past 4 decades. Australia has the highest incidence of skin cancer in the world.6 By 2011, it is
projected that melanoma will overtake lung cancer as the third highest cancer incidence for
Australian men. The rise in global incidence will undoubtedly put a significant strain on
every national healthcare system.

TYPES

There are three common types of skin cancer and more than 100 less common types.
Together, basal cell carcinoma, and squamous cell carcinoma are referred to as non-
melanoma skin cancers.

Basal Cell Carcinoma

Basal cell carcinoma (BCC) is the most common form of skin cancer, accounting for 75
percent to 80 percent of these cancers. The lifetime risk of developing a basal cell carcinoma
is around 30 percent. It was once found mostly in middle-aged or older people, but is

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increasingly being found in younger people. It is the most common skin cancer among
Hispanics.

Basal cell carcinomas are often shiny and have been described as "pearlescent." They may be
flat, raised, or dome-shaped, and are often pink, pale, or flesh-colored. On careful inspection,
tiny blood vessels may be visible when compared with the surrounding skin.

Basal cell carcinoma usually begins on areas exposed to the sun, such as the face, neck, and
hands. It is a slow-growing cancer that rarely spreads to other parts of the body, but people
with a history of BCC are at higher risk for getting a second case.

The cancer originates in the basal cell layer of the epidermis (the stratum basale). The basal
cells there mutate and begin to replicate uncontrollably. As the cancerous cells grow, they can
spread into the dermis, nearby lymph nodes, and may eventually invade bones. If not treated,
they can damage the surrounding tissue, causing disfigurement.

Treatments are very effective when these cancers are found and treated promptly.

Squamous Cell Carcinoma

Squamous cell carcinoma (SCC) accounts for 16 percent to 20 percent of skin cancers and
occurs twice as often in men as in women. These are the most common type of skin cancers
found in blacks.

Squamous cell carcinomas are often raised and feel crusty to touch. They can appear scaly
and may be ulcerated—that is, have a central depression that is lighter and flatter than the
surrounding area. These cancers sometimes bleed, ooze, or form scabs.

Unlike basal cell carcinomas, these cancers may spread (metastasize) if they become large. It
usually occurs on the face, ear, neck, lips, and backs of the hands. SCC can also begin within
scars or skin ulcers on other places on the body.

Squamous cell carcinomas have the strongest association with sun exposure

Melanoma

Melanoma is the most feared type of skin cancer. Though less common than basal cell and
squamous cell cancer, it is responsible for the majority of deaths from the disease as a whole.
Melanoma may arise in normal skin but often begins in an existing mole. It is found most
frequently on the back in men, on the legs in women, and on the palms of the hands, soles of
the feet, and under the fingernails or toenails of people of both sexes with darker skin colors.
That said, these cancers may occur anywhere, including areas of the skin that have never
been exposed to the sun.

Melanoma commonly presents as a change in an existing mole, or a new, abnormal appearing

mole .

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The incidence of melanoma has been rising dramatically in the United States for the last
three decades. While melanoma in general is 20 times more common in whites, the incidence
of cases that occur under the nails is similar for people of all skin color. In addition, the
survival rate in those diagnosed is lower in black people.

The prognosis of melanoma is good when found early, but drops precipitously when it
spreads to distant lymph nodes or organs, such as the bones, the lungs, the liver, and the
brain. Newer treatments, however, are making a difference in survival, and even some
advanced melanomas can now be controlled with these options.

Rare Types

The other types of cancer that can arise in the skin or skin-related structures are far less
common. A few of these include:

 Merkel cell carcinoma: Merkel cell carcinomas are rare skin cancers most often found
around the eye in middle-aged people. For unknown reasons, these cancers are increasing.
They tend to be aggressive and spread rapidly to other parts of the body.
 Kaposi's sarcoma: This cancer is caused by the Kaposi sarcoma herpesvirus, and is usually
found in people with HIV/AIDS or who are immunosuppressed for other reasons, such as an
organ transplant. It presents as large red, blue, or brown splotches around the body along with
swelling that can be severe. Fortunately, it often responds well to HIV medications.
 Sebaceous gland carcinoma: These cancers originate in sebaceous glands and occur most
often in older women, around the eye.
 Dermatofibrosarcoma protuberance: These cancers begin as a hard nodule that originates
in the dermis and spreads rapidly. They are related to a gene mutation that results in
overproduction of a protein known as a platelet-derived growth factor.

Skin Metastases and Other Cancers That Occur in the Skin

Sometimes, cancers that arise in other areas of the body may spread (metastasize) to the skin.
Cancers most commonly associated with skin metastases include breast cancer, colon cancer,
and lung cancer. When other cancers spread to the skin they are not classified as skin cancer.
In fact, though the cancer may now be affecting the skin, its cells are clearly identifiable as
belonging to the instigating cancer when examined under a microscope. Treatment for the
cancer at play, rather than skin cancer, is needed.

Some examples of this include inflammatory breast cancer, which often begins with redness
and a rash on the breast); Paget's disease, a form of breast cancer that begins on the skin of
the nipples; and cutaneous T cell lymphomas (including mycosis fungoides and Sezary
syndrome), which often begin as flat, red patches of skin that are extremely itchy.

Staging of skin Cancer

The stage of skin cancer is one of the most important factors in evaluating treatment
options. Non-melanoma skin cancers, such as basal cell carcinomas rarely spread and may
not be staged. The chance that squamous cell carcinomas will spread is slightly higher.

The American Joint Commission on Cancer has developed a uniform system for describing
the stages of skin cancer. This system allows doctors to determine how advanced a skin

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cancer is, and to share that information with each other in a meaningful way. This system,
known as the TNM system, is composed of three key pieces of information:

T (tumor): This describes the tumor’s size, location and how deep it has grown into the skin.

N (node): This indicates whether or not cancer cells have spread to nearby lymph nodes, or
the channels connecting the lymph nodes.

M (metastasis): This refers to whether the cancer cells have spread to distant organs.

Basal cell carcinoma stages

There are certain features that are considered to make the cancer at higher risk for spreading
or recurrence, and these may also be used to stage basal cell carcinomas. These include:

 Greater than 2 mm in thickness

 Invasion into the lower dermis or subcutis layers of the skin

 Invasion into the tiny nerves in the skin

 Location on the ear or on a hair-bearing lip

After the TNM components and risk factors have been established, the cancer is given a
stage. For basal cell carcinoma staging, the factors are grouped and labeled 0 to 4. The
characteristics and stages of basal cell carcinoma are:

Stage 0: Also called carcinoma in situ, cancer discovered in this stage is only present in the
epidermis (upper layer of the skin) and has not spread deeper to the dermis.

Stage I (stage 1 basal cell carcinoma): The cancer is less than 2 centimeters, about 4/5 of an
inch across, has not spread to nearby lymph nodes or organs, and has one or fewer high-risk
features.

Stage II (stage 2 basal cell carcinoma): The cancer is larger than 2 centimeters across, and
has not spread to nearby organs or lymph nodes, or a tumor of any size with 2 or more high-
risk features.

Stage III (stage 3 basal cell carcinoma): The cancer has spread into facial bones or 1 nearby
lymph node, but not to other organs.

Stage IV (stage 4 basal cell carcinoma): The cancer can be any size and has spread
(metastasized) to 1 or more lymph nodes which are larger than 3 cm and may have spread to
bones or other organs in the body.

21 | P a g e
Squamous cell carcinoma stages

There are certain features that are considered to make the cancer at higher risk for spreading
or recurrence, and these may also be used to stage squamous cell carcinomas. These
include:

 Greater than 2 mm in thickness

 Invasion into the lower dermis or subcutis layers of the skin

 Invasion into the tiny nerves in the skin

 Location on the ear or on a hair-bearing lip

After the TNM components and risk factors have been established, the cancer is assigned to
one of the five squamous cell carcinoma stages, which are labeled 0 to 4. The characteristics
and stages of squamous cell cancer are:

Stage 0: Also called carcinoma in situ, cancer discovered in this stage is only present in the
epidermis (upper layer of the skin) and has not spread deeper to the dermis.

Stage I (stage 1 squamous cell carcinoma): The cancer is less than 2 centimeters, about 4/5
of an inch across, has not spread to nearby lymph nodes or organs, and has one or fewer high-
risk features.

Stage II (stage 2 squamous cell carcinoma): The cancer is larger than 2 centimeters across,
and has not spread to nearby organs or lymph nodes, or a tumor of any size with 2 or more
high risk features.

Stage III (stage 3 squamous cell carcinoma): The cancer has spread into facial bones or 1
nearby lymph node, but not to other organs.

Stage IV (stage 4 squamous cell carcinoma): The cancer can be any size and has spread
(metastasized) to 1 or more lymph nodes which are larger than 3 cm and may have spread to
bones or other organs in the body.

SYMPTOMS

Signs and symptoms of skin cancer may include any change that is noted on the skin, such as:

 A sore that doesn't heal

 A mole that is changing
 Scaly, crusty appearing lesions
 Pink, white, or flesh-colored lumps that appear dome-like
 Itching

22 | P a g e
 Basal cell carcinomas are often shiny and have been described as "pearlescent." They
may be flat, raised, or dome-shaped, and are often pink, pale, or flesh-colored. On
careful inspection, tiny blood vessels may be visible when compared with the
surrounding skin.

 Squamous cell carcinomas are often raised and feel crusty to touch. They can appear
scaly and may be ulcerated—that is, have a central depression that is lighter and
flatter than the surrounding area. These cancers sometimes bleed, ooze, or form scabs.
 Melanoma commonly presents as a change in an existing mole, or a new, abnormal
appearing mole

Some refer to the ABCDE (and F) mnemonic to help them recognize when a skin change
could be skin cancer:

 A stands for asymmetry: A mole or sore that is asymmetric.

 B stands for borders. The borders of a melanoma may be irregular, notched, or blurry.
 C stands for color. Melanomas often have more than one color or hue.
 D stands for diameter. A mole that is larger than a pencil eraser is more likely to be a
melanoma.
 E stands for either elevation or evolution. The mole may be elevated (often irregularly) and is
often evolving (changing) over time.
 F: Though an unofficial qualifier, many add this to represent a skin change that is "funny"
looking.

In my patient

o A wound with discharge ,scaly appearance and scabs were present.

CAUSES AND RISK FACTORS

We don't know exactly what causes skin cancer, though we have identified several risk
factors. Some of these include:

 Sun exposure (especially extensive and/or unprotected)

 Pale skin
 Red or blonde hair
 Light eyes (green or blue eyes)
 Skin that rarely tans and burns easily
 Family and/or personal history of skin cancer
 Having one of several genetic syndromes, such as xeroderma pigmentosum
 Having many moles (more than 50) or having atypical moles (nevi)
 Scars from burns or previous skin infections
 A weakened immune system
 Use of some medical treatments and medications, such as radiation therapy for cancer and
ultraviolet light for psoriasis
 Frequent exposure to chemicals such as tar and vinyl chloride
 Exposure to arsenic in drinking water
 Smoking (increases the risk of squamous cell carcinoma)

23 | P a g e
 In my patient

 Exact cause is unknown but smoking might have been the predisposing factor.

PATHOPHYSIOLOGY

UV radiation penetrates the skin

Much of its energy is absorbed by the DNA of epidermal keratinocytes

UV-induced pyrimidine dimer formation

initial molecular step that leads to immune suppression

Mutation of the p53 tumor suppressor genes and production of reactive oxygen species

lead to the development of cancerous cells.

DIAGNOSIS

Diagnosing skin cancer begins with a careful history (paying attention to symptoms and risk
factors) and a physical exam. Based on the appearance of the skin lesion, a doctor may
recommend a biopsy, as it can sometimes be difficult to know whether an abnormality is
cancer or not based on its visible appearance. This can be even more challenging in non-
white populations.

A biopsy can be done in one of several ways, including:

 Shave biopsy: The most common if a basal cell or squamous cell carcinoma is
suspected), this procedure involves numbing the skin and shaving off a piece of the
lesion. A punch biopsy may also be done.
 Incisional biopsy: An incision is made and part of an abnormality is removed to be
viewed by a pathologist.
 Excisional biopsy: In this case, the entire abnormality is removed, along with an area
of surrounding tissue, for a pathologist's evaluation. This is done if a melanoma is
suspected.

24 | P a g e
If a skin cancer (melanoma and sometimes squamous cell carcinoma) is advanced, further
tests are done to stage the disease and search for the presence of metastases. These may
include a sentinel node biopsy, CT scans, a PET scan MRI , or other tests depending on the
location of the skin cancer.

In my patient

 History taking
 Physical examination
 Laboratory examination
 ECG
 USG of right thigh and both inguinal region
 USG of abdomen and pelvis
 Histopathology examination(rt inguinal lymphnode, lt inguinal lymphnode, wide local
excision from rt thigh region and rt deep inguinal lymph node)
 Biopsy of right inguinal lymph node (right)
 FNAC done(compatible with squamous cell carcinoma)
 CECT scan of abdomen and chest
 Plain and iv CECT scan of abdomen and pelvis
Investigations done in patient
Date Investigations Normal Units Result
range

2075/09/9 HPE report Inguinal region ,right

:excision
(TUTH)
biopsy,Squamous cell
carcinoma,well
differentiated

Right thigh FNA-S/O

2075/9/28 Cytopathology
Squamous cell
report(HAMS
carcinoma
Hospital)
Rt inguinal lymphnode
FNAC:Right thigh
FNA- Consistent with
and right inguinal
metastatic squamous

25 | P a g e
 lymph node cell carcinoma

2075/09/29 USG of Right thigh F/S/O malignant mass

and both inguinal at the anteromedial
region (Metro aspect of upper thigh
Kathmandu hospital with enlarged
PVT. LTD, referred malignant lymphnodes
by TUTH) on the subcutaneous
region along the medial
aspect of right thigh
and on the right
inguinal region
enlarged reactive left
inguinal lymh nodes

2075/10/15
Histopathological Well differentiated
examination report squamous cell
carcinoma
(Bir hospital)

26 | P a g e
 (biopsy from right T3N1MX, Stage III
inguinal lymph node,
biopsy from lt
inguinal lymph node,,
wide local excision
from rt thigh region
and biopsy from rt
deep inguinal
lymphnode)

Multiple necrotic
2075/11/1 CECT SCAN of chest
lymph nodes in rt
and abdomen
external iliac region
(Kundalini Diagnostic likely metastasis .ill
Centre: ref by defined soft tissue
National trauma lesion in lt inguinal
centre) region encasing the rt
common femoral
vessels and its
bifurcation likey
metastasis

K/C/O SCC of rt thigh

2076/1/13 Plain /IV CECT scan
of abdomen and pelvis -Heterogeneously
(Radiology and enhancing soft tissue
Imaging Department lesion in rt proximal
;Bir hospital) thigh including
inguinal region with
extension, invasion and
lymphadenopathy as
described above

27 | P a g e
 - heterogeneously
enhancing soft tissue
lesion rt pelvic cavity
with extension invasion
and
hydrouteronephrosis as
described
above.metastatic lymph
node

-calcified granulomas
in liver

-Mild
hepatosplenomegaly

-Lt renal cortical cyst

(Bosniak I)

Normal sinus rhythm

ECG

Haematology:

HB 15 Gm/dl
(13-18)
WBC 12000 /cu mm
(4000-11000)
Neutrophils 75 %
(40-75)
Lymphocytes 15 %
(20-40)
Platelets 332000 /cumm
(150000-400000)
Biochemistry:

28 | P a g e
 RFT:

Urea 34 Mg/dl (15-45)

Creatinine 0.9 Mg/dl (0.5-1.1)

Sodium 138 mEq/l (135-145)

Potassium 4.2 meq/l (3.5-5.5)

Serology

HIV I& II antibodies Non reactive

HBSAG Non reactive

Hepatitis C Non reactive

Mg/dl 70-140
RBS 100

TREATMENTS

1. Surgery

 Simple excision
 Curettage and electrodesiccation
 Mohs surgery(microscopically controlled surgery)
 Surgery for melanoma

2. Specialist Driven Procedures

 Cryosurgery
 Laser therapy
 Dermabrasion
 Topical Chemotherapy

3. Adjuvant therapy
4. Immunotherapy

 Immune checkpoint inhibitors

 Cytokines

5. Chemotherapy
6. Targeted therapy
29 | P a g e
  Signal transduction inhibitor therapy
 Angiogenesis inhibitors

7. Radiation therapy
8. Clinical trials
9. Complementary medicine(CAM)

In My Patient

1.Wide Local Excision

2.Chemotherapy

3. Radiation Therapy

30 | P a g e
 Flow chart showing the key roles for the general practitioner (green) in diagnosing, managing
and preventing skin cancer

31 | P a g e
 NURSING MANAGEMENT

1. Monitoring vital signs.

2. Maintaining optimal nutrition.
3. Prevention from infection.
4. Maintaining fluid volume.
5. Providing emotional support.
6. Providing wound care by proper dressing of the wound using asceptic technique.
7. Monitoring and management of potential complications.
8. Promoting home and community based care .
9. Administering chemotherapy.
10. Preparing patient for radiation therapy.

PREVENTION AND EARLY DETECTION

There are many things you can do to prevent skin cancer or at least reduce your risk. Being
careful in the sun is important, but includes more than just wearing sunscreen; using other
methods of protection (such as wearing clothing and hats, and avoiding mid-day sun) should
be practiced as well. Some occupational exposures may increase risk, and gloves are
recommended when working with many different chemicals and substances.

Not all skin cancers can be prevented, and early detection then becomes the goal. Self-skin
checks should be considered, especially for those who have any risk factors for the disease.
Some people who have significant risk factors or genetic syndromes associated with a higher
risk may want to consider regular visits with their dermatologist.

COMPLICATIONS

There are a number of complications that may occur with skin cancer. With non-melanoma
skin cancers, most of these are due to the local growth of the tumor. With melanoma,
complications may be related to the local growth of cancer, metastases to other parts of the
body, and side effects of the treatment options used. Possible complications include:

 Secondary Infection
 Scarring and/or Disfigurement
 Lymphedema
 Recurrence
 Metastases
 Anxiety and Depression

32 | P a g e
NURSING THEORY

Florence Nightingale’s Environmental Theory

Florence Nightingale “ the mother of the modern nursing ” considered nursing to be religious
calling to be fulfilled only by women. Her theory focused on environment.
Florence nightingale was born in Italy on May-12, 1820. Florence Nightingale describe
nursing as “ Nursing is the care which puts a person in the best possible condition for nature
to restore or preserve health to prevent or to cure disease or injuries. ’’
The environmental views as all external condition and influences that affect the life and death
and development of an organism and capable of preventing, suppressing or contributing to
disease or death. In her theory, she emphasize on 5 major components and three types of
environment.
The five components contain:
 Proper ventilation.
 Adequate light.
 Sufficient warmth.
 Control of noise.
 Cleanliness.
And three types of environment are physical, psychological and social. When one aspect of
the environment among these are out of balance or imbalance, the client must use increased
effort to overcome and need more energy to healing the environmental stress. These aspects
of the physical environment as also influenced by the social and psychological environment
of the individual. For early and proper recovery, good environment such as providing fresh
air, adequate nutrition, hygiene, light, comfort, calm and quiet environment, good
communication are necessary.
My patient Mr Prem Malla aged of 50 years is the case of squamous cell ca of skin. Among
the theory, I choose the Florence Nightingale’s Environmental theory because this theory is
appropriate to my patient. There is high risk to develop complication due to disease condition
and aging.

Physical Environment
Ventilation
Fresh air is most important for survival and breathing. There is also important to provide
proper ventilation .Avoid crowd and limited visiting of relatives.

Nutrition
Being either underweight or overweight can affect the symptoms, degree of disability and
prognosis of diseases.Nutrition helps to maintain health and promote immunity,prevent skin
break down .Therefore, I advised her to take nutritional diet to meet body’s requirement. I
encouraged her family to provide diet rich in protein and calorie .
.
Light, noise and water
Well lighting and well vantilated room and no noise by limiting the visitors and I also advised
her to take fluid according to body requirement and as ordered.

33 | P a g e
Warmth
The temperature of the room should be also maintained. I controlled the temperature by
maintaining appropriate ventilation and monitored patient’s body temperature. I also
provided her blanket to maintain warmth.

Cleanliness:
I maintained the cleanliness of my patient as I gave her an informal education on importance
of cleanliness and wearing clean cloths.

Psychological Environment
To maintain psychological environment, the following points to be remembered:
 Carefully listening to the patient’s problem and giving appropriate advice.
 Proper explanation about disease process, treatment and other procedures.
 Maintain good interpersonal relationship with the patient.
 Visitors are allowed to meet with the patient time to time.
 Diversion therapy was given according to the interest of the patient.
Social Environment:
The patient’s total environmental influences the patient’s room, hospital, home and the
community. The hospital should be well managed, eg. Clean, organized, appropriate supplies,
fully orientation. So, patient and his family did not suffer from unnecessary environment and
social stress thus patient felt happy, comfortable and feeling safe.

34 | P a g e
 NURSING CARE PLANS

1. Acute pain related to disruption of skin, tissue after surgical incision at right
thigh evidenced by patient’s verbalization of pain.
2. Fear related to diagnosis of cancer and uncertain prognosis.
3. Risk for infection related to surgical incision.
4. Disturbed sleep pattern related to discomfort as verbalized by patient
5. Altered body temperature related to effect of illness.

Defining Nursing Goal/ Planning Implementati Rationale Evaluatio

Characteristi Diagnosis Expecte on n
cs d
outcom
e

Subjective Acute pain Pain I will: I: The goal

Data: “I’m related to will be -document -documented -to evaluate was
having pain at disruption reduced location, location, the type of partially
of skin, to
my wound duration duration and pain and met as the
tissue after tolerable
site.” surgical limit and intensity of plan the patient
incision at within 1 intensity of pain. modality of verbalized
Objective pain. treatment about the
right thigh hour.
Data: -with evidenced reduction
facial grimace by patient’s in the
noted verbalizati -assess the -assessed the -to know if intensity
on of pain.
vital signs vital signs of the clients of the
of the the patient vital pain.
patient functions
are affected
by pain.

-provide -provided -to promote

comfort comfort relaxation
measures measures like and reduce
like positioning, muscle
positioning, mobilization. tension.
mobilizatio
n.

-encourage -encouraged -redirects

35 | P a g e
 the use of the use of the
diversional diversional patient’s
therapy like therapy like attention
reading reading books, from pain
books, talking about
talking his
about his interests,etc.
interests,etc
.

-administer -administered -helps

appropriate appropriate relieve pain
dose of dose of to its
analgesics analgesics if minimum
if pain still pain still not level
not relieved.
relieved.

-document -to make

the change -documented
the change in sure that
in the level the
of pain the level of
pain after all interventio
after all ns are
these these
interventions appropriate
interventio ly working
ns

Defining Nursing Goal/ Planning Implementati Rationale Evaluatio

Characterist Diagnos Expected on n
ics is outcome

Subjective Fear Patient and -Assess for -Patient’s -Assessment -Goal was
Data: “I related family will signs of signs of helps in fully
wonder when to demonstrat anxiety anxiety and effective achieved
is my illness diagnosi e reduced and fear. fear was planning and as patient
going to get s of level of assessed implementati and
cured.” cancer anxiety as which were on. family
and evidenced withdrawl, demonstra
Objective uncertai by use of crying te reduced
Data: -with

36 | P a g e
facial n positive restlessness, level of
grimace prognosi coping inability to anxiety.
noted s. strategies focus.
and
decrease
or absence -Assess -Assessed for -These may
of previous previous be useful in
fear,feelin successful successful dealing with
g of coping coping current crisis.
helplessne strategies. strategies
ss.
- Encouraged Verbalization
Encourage verbalization of actual or
verbalizati about feeling, perceived
on about grief, anger, threats can
feeling, fear and help to
grief, anxiety. reduce
anger, fear anxiety.Initial
and focus may be
anxiety. on the threat
of dying
rather than
reactions to
mastectomy.

-Stages of
- Reassured fear and grief
patient that over changes
-Reassure these feelings
or loss of
patient that are normal.
body part are
these
normal.
feelings
are -It corrects
normal. - Accurate
misinformati
information
on and
-Provide about the
provides new
accurate future with
treatment
informatio skin cancer
option and
n about the provided.
prognosis.
future with
skin
cancer . -Assisted in
-Modification
-Assist in use of
may be
use of previous
necessary for

37 | P a g e
 previous successful this specific
successful coping problem.
coping measures.
measures.

- -These may
Administer -Tab facilitate
anti diazepam ability to
anxiety o.5mg P/O HS cope.
medicine administered.
as order
and
indicated.

Nursing Nursing Nursing Plan of Rationale Interventio Evaluatio

assessme diagnos goal action n n
nt is

Subjectiv Risk for Risk will -Assess -It helps to obtain -General Goal was
e data: infectio be the general baseline data and to condition not met as
not n related minimiz condition, detect early signs of and signs patient
applicable to ed vital signs, infection. of infection did
. surgical through and signs were develop
incision. out the of assessed, fever.
hospital infection. Vital signs
stay. were
monitored
and
recorded.
Objective -Advice
data : -Hand washing is
for hand - Advised
basic and important
washing to for hand
means of infection
patient and washing to
prevention.
patient’s patient and
party patient’s
before party
each before each
procedure. procedure.

-Maintain - Aseptic
-It prevents cross
aseptic techniques
infection.
technique were
while maintained

38 | P a g e
 doing any while doing
procedure. any
procedure.
-Dressing
daily with -It prevents and - Daily
betadine inhibits the growth of dressing
solution micro-organisms. with
under betadine
aseptic solution
technique. under
aseptic
technique
was done.

-Exclude -Helps to protect from - visitors

visitors exposure to with
with infection/microorganis infectious
infectious ms. disease
disease. were
excluded .

-
Encourage Encouraged
-It is important to keep
to take to take
healthy and for normal
adequate adequate
physiological process.
fluid and fluid and
nutritious nutritious
diet. (high
protein)
diet.

-
-
Administe
Administer
r
-It prevents infection. ed
antibiotics
antibiotic
according
according
to
to
prescriptio
prescription
n.
.

39 | P a g e
Nursing Nursing Nursing Plan of Rationale Interventio Evaluatio
assessmen diagnosis goal action n n
t

Subjective Disturbed Patient To assess Patient It help for Patient

data: sleep sleep the patient condition is further sleep
patient pattern pattern condition assessed intervention pattern is
said” I am related to will be improved
unable to discomfor improve as
sleep at t as d with in verbalized
night due verbalized 1weeks by patient
to pain on by patient
the wound
To provide Quiet It helps to
site”
quiet environmen induce sleep
environmen t is to the
t to the provided to patient
patient the patient
Objective
data:
Patient To provide
analgesic as It also helps
does not
ordered to Analgesic is to reduce
look fresh
the patient provided to pain
at morning
the patient

To change It helps to
the patient provide
frequently comfort to
Patient the patient
position is
changed
frequently

Nursing Nursing Nursing Plan of Rationale Interventio Evaluatio

assessmen diagnosis goal action n n
t

Subjective Altered Temperatur -Assess -Condition -It helps to Patient's

Data : body e will be the of pt. diagnose temperatur
temperatur reduced to patient’s assessed. degree of e was
Patient e related 98.60 F severity & reduced to

40 | P a g e
says, "I am to effect within an condition. aids in quick normal i.e.
feeling hot of illness. hour. intervention. 98.60 F
in my within an
whole hour.
body". Thus, my
-All extra goal fully
clothes & -Helps to met.
-Remove blanket reduce
Objective all extra were
Data : temperature
clothes & removed through
Patient blanket from body. radiation.
looks from the
weak, body.
Temperatu
re 1020 F,
Diaphoresi -Cross
s ventilation
-Maintain maintained -Helps to
cross by opening reduce
ventilation windows temperature
in the & through
room by controlling convection.
opening visitors.
windows
&
controllin
g visitors.

-Cold -Helps to
compress reduce
-Apply & cold temperature
cold sponges through
compress over the conduction.
& cold body
sponge. provided.

-Patient is
given to
- -It helps to
drink
Encourage plenty of prevent
patient for fluids. dehydration.
intake of

41 | P a g e
 plenty of
fluids.

-Tab. -It acts on

paracetam temperature
ol 500mg regulating
-Provide PO centre
Tab. provided hypothalam
paracetam us & helps
ol 500mg in reducing
PO temperature.

DRUGS USED IN MY PATIENT

A. Pantoprazole:
It is also the proton pump inhibitor . It is highly bound toplama proteins about 98%
.plasm concentrations of this medicine achieved in 2 to 2.5 hours after a dose by orally.
Preparation :
It is usually available in the form of tables and injection such as :
Pantoprazole tables 20mg, 40mg
Pantoprazole injection 40mg in vials

Dose:

Adult:

40mg OD by mouth for 2-4 weeks

Inj IV: 40 mg (1 vial) once daily slow IV injection or by IV infusion

Drug interaction:

Similar to Omeprazole
Adverse effect :
CNS: headache ,depression
GIT: diarrhea,nausea , flatulence
Skin: skin eruption,skin rash

42 | P a g e
 Miscellaneous: fainting,oedemaformation,and fever
Contradiction:
Hypersensitivity
Alert Box

There is no information about the safety of Pantoprazole during pregnancy

and breast-feeding mother.Th e medicine should not be used unless the
benefit exceeds the potential risk.There is no information on the use of
Pantoprazole in children.

Nursing Implication:


Capsules should not be chewed because of enteric coated pellets.

It should be taken before meal.

Advice patients to take the full course.

The drugs should not be taken with anatacids.

Pantroprazole I.V is available in strength of 40mg in vials along with diluents
10ml of sodium cholride injection 0.9% w/v in ampoule.
 The recommended dose of Pantropazole should be administered either by slow
I/V injection or by I/V infusion over 2-15 minutes.
 It is an alternative in patients for whom oral administration of Pantoprazole is not
indicated.Prior to treatment of gastric ulcer,the possibility of malignancy should
be excluded as treatement with Pantprazole may alleviate the symptomp of
malignant ulcers and can thus dealay diagnosis.
B. Morphine

It is also called morphine and hydromorphone.

Mode of action

Depress the pain impulse transmission at the spinal cord level by interacting with opioid
receptor.

Dose

4-20 mg qid

Side effect

CNS: Drowsiness, dizziness, confusion, headache, sedation

CV: Palpitation, bradycardia, change in BP, shock, Cardiac arrest

GI: Nausea, vomiting, anorexia

HEMA: thrombocytopenia

RESP: Respiratory depression, respiratory arrest, apnea

43 | P a g e
 Contraindication

Hypersensitivity, addiction, hemorrhage, bronchial asthma, increased intracranial pressure

Nursing consideration

Store in light resistant container at room temperature.

To change position slowly, orthostatic hypotension may occur.

To report any symptoms of CNS changes, allergic reaction

To avoid use of alcohol

Withdrawal symptoms should be monitor

C. Voveran:
Generic Name: Diclofenac Sodium
Functional Class: Non-Steroid anti inflammatory products
Chemical Class: Phenyl acetic acid

Mechanism of action: Inhibits prostaglandin synthesis by decreasing enzyme needed for

biosynthesis; analgesic, anti-inflammatory, antipyretic

Uses: Acute, chronic rheumatoid arthritis, osteoarthritis, ankylosing spondylitis, analgesia,

primary dysmenorrhoea

Dosage and Route:

Analgesia:
Adult: PO 50 mg tid, max 150 mg /day

Side Effects: headache, dizziness, drowsiness, confusion, insomnia, paresthesia, muscle

weakness, CHF, peripheral edema, palpitations, dysrhythmia, nausea, tinnitus, gastritis, GI
bleeding, hamoptysis, nephrotoxicity, purpura, rashes, bronchospasm, anaphylaxis

Contraindications: hypersensitivity to aspirin, iodides, oThere NSAIDs, asthma, serious CV

disorders.
Precautions: pregnancy, breast feeding, children, bleeding disorders, GI disorders, cardiac
disorders
Hypersensitivity to other anti-inflammatory agents, Ccr <30ml/min

Nursing Considerations:
Assess:
 For pain: location, character, aggravating and alleviating factors
 Blood counts during Thereapy, LFT, uric acid, BUN, creatinine, electrolytes
Administer:
 Do not break, crush, or chew enteric products
 Take with one glass of water to enhance absorption
Evaluate:

44 | P a g e
  Therapeutic response: decreased inflammation in joints, decreased inflammation after
cataract surgery
Teach patient/ family:
 To report bleeding, bruising, fatigue, malaise; blood dyscrasias do occur.
 To avoid aspirin, alcoholic beverages, NSAIDS, acetaminophen or oThere OTC.
 To take with food, meals or other antacids to avoid GI upset.
 To report hepatotoxicity: jaundice, nausea, vomiting, pruritus, lethargy.
 To use sunscreen to prevent photosensitivity.

D. Paracetamol

 Generic Name : Paracetamol/Acetaminophen

 Trade Name : Amul 500, Cemol, Femol, Niko, Cetamol, Monomol
 Therapeutic class : Antipyretic

ACTION :

It is non narcotic analgesic that inhibits prostaglandin synthesis in the CNS .It has
weak anti inflammatory activity .

INDICATION :

- Analgesic and antipyretic of choice in children

- Antipyretic in adults

- As weak analgesic in adults

PREPARATION :

It is usually available in tablet, syrup and inj. form such as :

paracetamol tab of 500mg

syrup of 120mg/5ml

Inj. of 150 mg/ml(2ml)

DOSE :

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 - Adult - 500 to 1000mg TID/QID sos
- Child - less than 3 months 10mg/kg, above 3 months (10-15) mg (3-4) dose/24 hrs.

CONTRAINDICATION :

- Renal insufficiency
- Hepatic disease
- Anaemia
- Hypersensitivity

SPECIAL PRECAUTIONS :

- Use cautiously in hepatic failure.

- Possibility of gastric malignancy to be excluded in prolonged use.
- se cautiously in pregnant women.
- Infusion over 15 minute at a rate not to exceed 5mg/min.

ADVERSE REACTIONS :

- Skin rash and minor allergic reactions

- Renal tubular necrosis and hypoglycemic coma with prolonged large dose therapy
- Hepatic necrosis and liver failure in toxic doses
- Headache, depression, insomnia, dizziness
- Diarrhoea, nausea, vomiting, dyspepsia
- Chest pain
- Fainting, oedema, fever

NURSING CONSIDERATIONS:

- Individuals with poor nutrition and alcoholics are prone to hepatotoxicity with
moderate dose
- Overdose and chronic use can cause liver damage
- Advise patient to take the full dose

E. Olanzapine

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Olanzapine oral tablet is available as brand-name drugs and generic drugs. Brand names:
Zyprexa, Zyprexa Zydis

Mechanism of action

Olanzapine belongs to a class of drugs called atypical antipsychotics. A class of drugs is a

group of medications that work in a similar way. These drugs are often used to treat similar
conditions.

It’s not known exactly how olanzapine works. It’s thought that it may help to regulate the
amount of certain chemicals (dopamine and serotonin) in your brain to help control your
mood.

Indications

Olanzapine is used to treat schizophrenia and bipolar I disorder. It’s also used with fluoxetine
to treat other conditions. These include depression caused by bipolar I disorder as well
as depression that can’t be controlled with other drugs.

Drug forms and strengths

Generic: Olanzapine

 Form: oral tablet

 Strengths: 2.5 mg, 5 mg, 7.5 mg, 10 mg, 15 mg, 20 mg

 Form: oral disintegrating tablet

 Strengths: 5 mg, 10 mg, 15 mg, 20 mg

Side effects

 orthostatic hypotension (low blood pressure upon standing after lying down or sitting)

 lack of energy

 dry mouth

 increased appetite

 tiredness

 tremor (shakes)

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  constipation (hard or infrequent stools)

 dizziness

 restlessness

 changes in behavior that might be considered offensive to others

 weight gain

Nursing considerations

General

 You can take olanzapine with or without food.

 Take olanzapine at the time(s) recommended by your doctor.

 You can cut or crush the tablet.

Storage

 Store olanzapine at room temperature between 68°F and 77°F (20°C and 25°C).

 Keep this drug away from light.

 Don’t store this medication in moist or damp areas, such as bathrooms.

Refills

A prescription for this medication is not refillable. You or your pharmacy will have to contact
your doctor for a new prescription if you need this medication refilled.

Travel

When traveling with your medication:

 Always carry your medication with you. When flying, never put it into a checked bag.
Keep it in your carry-on bag.

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 Don’t worry about airport X-ray machines. They can’t harm your medication.

 You may need to show airport staff the pharmacy label for your medication. Always carry
the original prescription-labeled container with you.

 Don’t put this medication in your car’s glove compartment or leave it in the car. Be sure to
avoid doing this when the weather is very hot or very cold.

Self-management

Tips for taking the orally disintegrating tablets (Zyprexa Zydis):

 Be sure that your hands are dry.

 Open the sachet and peel back the foil on the blister. Don’t push the tablet through the foil.

 As soon as you open the blister, remove the tablet and put it into your mouth.

 The tablet will dissolve quickly in your saliva. This will help you swallow it easily, with
or without drinking liquid.
F. Dulcolax

Generic Name: bisacodyl (oral and rectal)

Brand Names: Dulcolax Laxative

Uses

Bisacodyl is used to treat constipation. It may also be used to clean out the intestines before a
bowel examination/surgery. Bisacodyl is known as a stimulant laxative. It works by increasing
the movement of the intestines, helping the stool to come out.

Side effects

Stomach/abdominal pain or cramping,

nausea,

diarrhea,

weakness

persistent nausea

vomiting

irregular heartbeat,

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dizziness,

fainting,

decreased urination,

mental/mood changes (such as confusion)

Nursing consideration

Take this medication by mouth as directed by your doctor. If you are self-treating, follow all
directions on the product package. If you are uncertain about any of the information, ask your
doctor or pharmacist.

Swallow this medication whole. Do not crush, chew, or break the tablet or take it within 1 hour of
antacids, milk, or milk products. Doing so can destroy the coating on the tablet and may increase
the risk of stomach upset and nausea.

Dosage is based on your age, medical condition, and response to treatment. Do not increase your
dose or take this drug more often than directed. Do not take this medication for more than 7 days
unless directed by your doctor. Serious side effects may occur with overuse of this medication
(see also Side Effects section).

It may take 6 to 12 hours before this medication causes a bowel movement. Tell your doctor if
your condition persists or worsens, or if bleeding from the rectum occurs. If you think you may
have a serious medical problem, seek immediate medical attention.

STRESS MANAGEMENT & DIVERTIONAL THERAPY

Stress is a state produced by change in environment. It is a factor which pressurize mentally

or physically and adversely affects the functioning of body. When stresses more sense or
prolonged, a person needs divisional therapy or coping mechanism.

It is a change in the environment that is perceived as a threat, challenge or harm to the

person’s dynamic equilibrium. Every person finds it difficult to adjust to new environment. It
takes time to adjust. In these conditions one feels anxious and wants to demand safety and
security. Even in the best hospital setting a patient psychologically feels strange, conflicting
and frightening isolated and lonely in spite of many people around.

The following side effects may be seen:

 Forced dependency

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  Strange authority figures
 Dramatic change in physical environment
 Disturbed daily routines
 Increased anxiety
 Forced adjustment
 Loss of privacy and freedom

To minimize the stress of patient.I provided the following activities:

 Provide psychological support showing another patient.

 Encourage his family member to stay with her as possible.
 Providing time to express her feelings about disease and hospitalization, fear and
emotion.
 Try to provide calm and quiet environment.
 Providing informal health teaching as patient’s need.
 Encourage family members to visit the patient frequently.
 Give information about the disease condition.

Progressive muscles relaxation:

It helps in relieving muscle tension related to stress. I have advised my patient to tense
muscle than relax slowly alternately until the entire muscle feels relax.

Distraction therapy:

In this technique I have advised family members to visit patient for some time one by one
and talk to her.

Diversion therapy:

The therapy which divert the mind of patient. In this therapy I have advised the patient to talk
on other interesting topics which he likes.

Relaxation breathing:

This is simple technique that can be performed at any time. For relaxation breathing I
encouraged my patient to breathe slowly and deeply until relaxation is achieved.

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TEACHING DURING HOSPITALIZATION

Health teaching is an important part while providing care to the patient as well as family
member. It is integral part of admission till the discharge including follow up visit /care .so it
is our responsibility to suggest the patient and family member.

Health promotion and maintenance are important science. Health status is a good indicator of
one’s ability to adapt to the rapid changes. The health teaching helps to provide better
changes and optimal health. It is one of the most important roles of the nurse to provide
health education. So, I being a nurse and I gave health teaching to my patient,family members
as per needed during the period of hospitalization .

Therefore I had given health teaching on different topics.

Which are as follows:-

 Nutrition
 Rest and sleep
 Exercise
 Personal hygiene
 Medication

1-Nutrition

Nutrition is very important and balance diet including protein, carbohydrate, vitamin and
minerals.

I advised him to have low fat diet, green leafy vegetables,plenty of fluid and I also gave
teaching to have dairy proucts like milk, cheese etc ,to create high protein diets for chemo
patients.

• In addition-, nuts,, green vegetables and legumes are sources of high protein.
• Raw and uncooked foods should be avoided.
• Plenty of fluids to be encouraged.

2-Rest and sleep /activities

Rest and sleep is very important is this period for the recovery

3-Personal hygiene

I advised him to maintain personal hygiene by keeping the wound site dry, handwashing,
trimming nail short ,bathing and wearing clean clothes.

4-medicine

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I gave teaching about regular medication time duration and certain side effect of medicine to
his family and patient it self to take prescribe medicine. I explain about why these medicine
are needed .These medicine should take after meal and seek medical facilities if any side
effect occur.

SUMMARY OF CASE STUDY

During my posting in chemo medical ward , I got opportunity to observe different types of
cases in the ward and provide nursing care to them according to their need. There I got
opportunity to select a case study in chemo medical ward. My case study is carcinoma of
skin.

He was Mr. Prem Malla aged 50 years admitted on 2076/1/ 17 with diagnosis of squamous
cell carcinoma of skin. He was admitted in chemo medical ward as referred for radiation
therapy from Bir hospital.

I provided holistic care to the patient considering his physical, psychological, mental, social
cultural aspect. I provided the care following nursing process. I provided health teaching on
different types according to his need and level of understanding.

He was provided with nursing care and informal teaching on promotive and
preventive aspects of health. This case study includes his detail information, history, book
practice, details on disease, progress note, nursing care plan, holistic health care, application
of nursing theory, discharge teaching, recreational activities etc. and I had provided different
diversion therapy to the patient for stress management.

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WHAT I LEARNT FROM THIS CASE STUDY?

Case study is a very good approach for the student to learn about the disease and nursing
practice in depth. It gives us comprehensive knowledge about a specific disease and related
with real situation. It is suitable way of applying theory in practice in real situation. Here are
some points when i learned from this case study.

a) About the disease

I studied about this disease in depth by the resource available in literature, research,
interest and some journals. I also obtained information from patient, and visitor . I
know about this disease it causes predisposing and get chance to compare all these
with real case.
b) About the patient
Through this case study i got the opportunity to know the history of the patient, his
personal family, social, occupational, educational as well as present and past health
history, his habit, way of living, way of thinking and its influence on health and
illness. I also got a chance to compare normal developmental task.
c) About the family and environment
I got the information about my patient family background, concept about health and
illness, nutrition, economic status, disease and treatment.
d) About nursing care
I applied holistic approach while proceeding nursing care to the patient, i also applied
Florence Nightingale’s Environmental theory of nursing while caring my patient. I gain lot of
knowledge about care plan
e) About document
Documentation is also the most important and useful skill. So, through this case study
my skill of documenting was tremendously improved. I could formulate the case
study symmetrically and deeply.
f) About hospital policy
During my case study, i learnt about the routine care performed ward, investigation
procedure, medication policy like supplies, different unit and available resource as
well as process of reporting and recording.

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REFERENCES

1. Brunner and suddarth’s Textbook of Medicical Surgical Nursing, Lippincott

Company,Philadelph tweleve edition volume-2
2. BT Basavanthappa Medical Surgical Nursing 1st edition. Jaypee brothers Medical
Publishers (P) Ltd, New Delhi India.
3. Timilsina Rekha, "Comphrehensive Textbook Of Geriatric Nursing" First Edition
2015, Samiksha Publication Pvt Ltd, Pg No.125-129
4. Kisi Durgeshori, Shrestha Rhinu "A Textbook Of Geriatric Nursing"First Edition
2014 , Vidhyarthi Pustak Bhandar Page No-80-82
5. "Text book of Adult nursing" HMG, FIFTH EDITION
6. Rai,B (2016)A textbook of oncology nursing,1st edition, Bhotahity, Kathmandu
Nepal heritage publishers &distributors pvt.ltd,unit-4 page no (25-28)
7. RoshaniTui Tui pocket book of drug, first edition 2oo3 Makalu .
8. Saunders, nursing drug handbook, 2012, published by Elsevier, 2nd edition
9. Rai Lalita,Nursing concept ,theories and principles,2nd edition 2011 pg=195-
198
10. https://www.verywellhealth.com/skin-cancer-treatment-3010859
11. https://nursing.ceconnection.com/ovidfiles/00129334-200912000-00014.pdf
12. American Cancer Society. Cancer Facts & Figures 2008. http://www.cancer.org/downloads/
STT/2008CAFFfinalsecured.pdf. Last accessed March 28, 2008.

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