I.

INTRODUCTION

(random info. abt her condition and dont start with nasal carcinoma abruptly)

"Paranasal" means near the nose. The para sinuses are hollow, air-filled spaces in the bones

around the nose. The sinuses are lined with cells that make mucus, which keeps the inside of the

nose from drying out during breathing.

The nose opens into the nasal cavity, which is divided into two nasal passages. Air moves
through these passages during breathing. The nasal cavity lies above the bone that forms the roof
of the mouth and curves down at the back to join the throat. The area just inside the nostrils is
called the nasal vestibule. A small area of special cells in the roof of each nasal passage sends
signals to the brain to give the sense of smell.

Together the paranasal sinuses and the nasal cavity filter and warm the air, and make it moist
before it goes into the lungs. The movement of air through the sinuses and other parts of the
respiratory system help make sounds for talking.

Paranasal sinus and nasal cavity cancer is a type of head and neck cancer. (National Cancer
Institute, 2021)

A 47-year old female was admitted in Ciudad Medical Zamboanga on September 3, 2022 with

admitting diagnosis of Nasopharyngeal carcinoma stage IV A. with multinodular toxic goiter;

type II Diabetes Mellitus, insulin requiring. Client underwent 8th cycle of Chemotherapy and

Blood Transfusion on September 4, 2022

Prior to admission, the patient already had an Ultrasound of anterior neck due to complaints of

pain and nodules that are noticeable in Pagadian Diagnostic Center and completed 35

Radiotherapy sessions on June 13, 2022

Significance of the Study

The study conducted to benefit the following:

I. Nursing Education

This study is an opportunity to apply theoretical learning to the situation presented in the

case study. This study will provide more learning and knowledge on care for patient undergoing

chemotherapy treatment related to nasopharyngeal carcinoma. This information will serve as

guide for the future nurses as it will be very beneficial for their learnings; it will help the student

nurses to become more aware and at the same time enhance their skills and decision making

especially in improving quality of life of patient with nasopharyngeal carcinoma, thus it will help

them prepare for their duties as a nursing care profession.

II. Nursing Practice

This information given will help guide student nurses in their practices, and will help

them become more critical about the situation. Because of the new knowledge acquired, the

student nurse will improve their skills on handling patients in the hospital. This case study will
also help nurses research more information to advance their medical field background and

become more updated about new cases in order to provide better patient care.

III. Nursing Research

The purpose of this research is to provide foundation in nursing practices and to be able

to do nursing process such as assessing, planning, intervening, and evaluating effectively. This

research will also give knowledge as it helps to identify patient conditions accurately. Also, this

nursing research seeks to prevent illness and spread awareness, as well as to protect and improve

patient’s health and alleviate suffering.

Objectives

General Objective: Acquisition and application of knowledge, skills and attitudes through the

utilization of nursing process and performance of professional management and leadership skills

in the care of sick adult clients with life-threatening conditions, acutely ill/ multi-organ

problems, high acuity and emergency situation toward health promotion, disease prevention,

restoration and maintenance and rehabilitation.

Learning Objectives:

At the end of this case study, the researchers will be able to:

1. Formulate an appropriate nursing care plan as a priority to restore and maintain health

while undergoing chemotherapy.

2. Formulate teaching plan in coherence with the condition of the patient.

3. Conduct health education on Gastrostomy Tube care.

4. Execute the mode of management of nasopharyngeal carcinoma

 5. Accomplish a thorough and integrated study and research on Nasopharyngeal carcinoma

6. Gain knowledge and understanding about the pathophysiology of Nasopharyngeal

Carcinoma.

7. To be able to distinguish the clinical manifestations, signs and symptoms, risk factors,

and possible complication of the condition, as well as note the complaints experienced by

the patient.

8. Identify the significance of the laboratory and diagnostic examinations and interpret its

results.

9. Relate the clinical manifestations of the disorder and the data (such as laboratory results)

to the associated pathophysiology alterations systematically.

10. Implement effective nursing interventions that prevent further aggravation of the patients

condition.

11. Evaluate honestly the overall outcome of the case study.

Anatomy and Physiology

Anatomy
 The Nasopharynx along the oropharynx and hypopharynx is a part of the throat that is

located behind the nasal cavity above the oropharynx and above the soft palate.

Important Structures in Relation to the Nasopharynx

● Choanae: This is the entrance from the back of the nose (behind the nasal septum) into

the nasopharynx.

● Adenoids / Lymphoid tissue: Adenoids are a subepithelial collection of lymphoid tissue,

which is present at the junction of the roof and posterior wall of the nasopharynx. They

increase in size up to the age of 6 years and after that gradually atrophies.

● Eustachian/Auditory Tubes: It is sometimes called the auditory tubes that lie on either

side of the nasopharynx and are connected to the middle ear.

● Torus Tubarius: Torus tubarius is the medial cartilaginous extension of the auditory

(eustachian) tube which forms a protrusion on the lateral wall of the nasopharynx at the

superior and posterior aspects of the opening of the auditory tube.

● Tubal Tonsil: This collection of subepithelial lymphoid tissue is continuous with

adenoid tissue and forms a part of the Waldeyer’s ring. It is situated at the tubal elevation.
 ● Pharyngeal Recess (Fossa of Rosenmüller): Its sit-like space behind the opening of the

Eustachian Tubes into the nasopharynx.

● Base of Skull: The nasopharynx is located right below and in front of the base of the

skull. On the other side of the base of the skull is the brain.

● Retropharyngeal Space: It is a space behind the pharynx in front of the spine.

● Muscles: Pharyngeal constrictor muscles, the levator palatini muscle are two muscles in

close relation with the nasopharynx.

● Sinus of Morgagni: Is a defect in the lateral pharyngeal wall at the level of nasopharynx,

formed due to dehiscence in superior constrictor muscle, which fails to reach the base of

the skull. This gap is bridged only by pharyngobasilar fascia.

It is through this opening the eustachian (auditory) tube along with its two muscles enter

the nasopharynx. The Ascending palatine artery, which is a branch of the facial artery

also runs through this sinus.

● Rathke’s Pouch: This dimple above the adenoids (junction of nasal septum and roof of

nasopharynx) is reminiscent of the buccal mucosal invagination, which forms the anterior

lobe of the pituitary.

● Nasopharyngeal Bursa: Its an epithelial lined median recess, which is seen within the

adenoid mass, extends from pharyngeal mucosa to periosteum of basiocciput. Bursa

represents the embryonic site of attachment of notochord to the pharyngeal endoderm.

● Passavant’s Ridge: This is a mucosal ridge, which encircles the posterior and lateral

walls of the nasopharyngeal isthmus. It is formed by fibers of palatopharyngeus muscle.

Physiological Function of The Nasopharynx

 ● Airway: Nasopharynx acts as a conduit for air to its way to the larynx and trachea. It

connects the nose to the respiratory system.

● Middle ear ventilation: Eustachian tube ventilates the middle ear and equalizes air

pressure on both sides of the tympanic membrane. Dysfunctions of the Eustachian tube

can affect the middle ear and cause hearing problems.

● Immunity: It contains adenoids, which help prevent infection.

● Resonance: It is a part of the resonating chamber for voice production. Nasopharyngeal

obstruction and velopharyngeal incompetence produce changes in voice.

● Drainage: It is a drainage channel for nasal and nasopharyngeal mucous secretions. It is

connected to the eustachian tubes from the ears which drain fluid and balance pressure.

Physiology of The Important Structures of The Nasopharynx

● Choanae: If a tumor blocks one of these, this causes the blockage of airflow and makes it

difficult to breathe from that side of the nose.

● Eustachian Tubes: It helps in equalizing the pressure that is in the ear and drains mucus

in the middle ear. If there is a presence of nasopharyngeal tumor in either one of the

eustachian tubes, it will cause the build up of mucus in the middle ear which could cause

hearing impairment or ear infection.

● Tubal Tonsil: Enlarged or infected tubal tonsils can block the Eustachian tube, leading to

hearing problems.

● Pharyngeal Recess (Fossa of Rosenmuller): Is a hidden area in regular post nasal

examination and is the commonest site of nasopharyngeal carcinoma. Hence it is also

called as “Coffin’s corner” – malignancies arising in FOR may go unnoticed and will

present in late-stage with poor prognosis. The FOR opens into the nasopharynx at a point
 below foramen lacerum and is considered as a landmark for carotid arteries in endoscopic

skull base surgeries.

● Base of Skull: An advanced nasopharyngeal cancer can destroy the bone at the base of

the skull which creates an entrance to the cranial cavity and may affect the brain.

● Retropharyngeal Space: It is where nasopharyngeal cancers can spread to the lymph

nodes in this space.

● Sinus of Morgagni: Only a membrane-bound region, nasopharyngeal tumors can easily

breach this area and spread into the parapharyngeal space.

● Rathke’s Pouch: A craniopharyngioma may arise from Rathke’s pouch.

● Nasopharyngeal Bursa: Tornwaldt’s disease is an abscess that develops in the

nasopharyngeal bursa. Infected bursa usually presents with persistent postnasal discharge

or crusting.

● Passavant’s Ridge: When soft palate contracts during deglutition or speech, it makes

firm contact with Passavant’s ridge and cuts off nasopharynx from the oropharynx.

● Nasopharyngeal Isthmus: It cuts off nasopharynx from oropharynx during swallowing,

vomiting, gagging and speech.

Pathophysiology

Nasopharyngeal Carcinoma

The development of nasopharyngeal carcinoma depends on multiple factors, such as

genetic susceptibility, environmental factors, and infections such as Epstein-Barr virus (EBV)

infection. Many studies linked multiple genes to the pathogenesis of the NPC; one of these genes
is a region in human leukocyte antigen (HLA) genes at chromosome 6 (Almomani, Zulfiqar, &

Nagalli, 2022).

Epstein–Barr virus (EBV or human herpesvirus 4) causes infectious mononucleosis and

is latent in most adults. EBV is commonly transmitted by infected saliva (hence the nickname the

kissing disease). Primary infection involves epithelial cells of the oropharynx and parotid gland.

Viral shedding occurs for weeks to months after infection. Following replication in epithelial

cells, EBV infects B cells and quickly becomes latent. Latent EBV is a factor in the development

of nasopharyngeal carcinoma, Burkitt's lymphoma, and other lymphoproliferative disorders in

immunocompromised individuals.

Host genes are not the only ones linked to the pathogenesis of NPC (Nasopharyngeal

Carcinoma). EBV (Epstein-Barr Virus) is significantly related to NPC, as there are studies that

show the various processes and mechanisms that EBV can activate or inhibit in the host cell.

The host cells are affected by RNA molecules or encoded-proteins that are brought by EBV. The

molecules are, but not restricted to:

● Latent membrane protein (LMP1): a membrane protein encoded by EBV, and plays an

important role in the induction of tumorigenesis, in other words, the formation of a

tumor.

● Latent Membrane Protein 2A (LMP2A): a membrane encoded in the viral DNA that

increases the invasive and migratory properties of the virus.

● MicroRNAs(miRNA): non-coding RNA molecules that have regulatory functions in gene

expression processes and influence cell function and division.

● Other molecules: Metastatic Tumor Antigen 1 (MTA1), which is linked to tumor

metastasis. Epstein-Barr nuclear antigen 1 (EBNA1), which localizes to the nucleus and
 has various roles, which includes binding to cellular and viral genomes, regulation of

signaling pathways, and gene transcription

II. NURSING PROCESS

A. Assessment

Biographic data:

Name: Patient J
 Age: 47 years old

Address: Purok 8, Gate 1 UPPER Calarian, Zamboanga City

Philippines 7000
Status: Single

Chief complaint: Patient is for chemotherapy

History of Present Illness:

Patient J was admitted to Ciudad Medical Zamboanga on September 03, 2022 for her 8th cycle

of chemotherapy. She was diagnosed with nasopharyngeal cancer last May of 2021. Underwent

chemotherapy 7 times then was ordered for 3 more cycles. Radiotherapy of 35 sessions was also

completed on June 12, 2022.

History of Past Illness:

Patient J was diagnosed with nasopharyngeal carcinoma in 2021. She has diabetes mellitus

insulin-requiring and a multinodular toxic goiter. She had a g-tube insertion this year, May 2022.

She does not have a history of hypertension, does not smoke, drink, and is not unemployed. She

has maintenance medicines which are: atorvastatin, ferrous sulfate, and propylthiouracil.

Family History:

She has a history of diabetes on her father's side of the family.

B. Diagnostic Test

TEST RESULTS NORMAL RANGE CLINICAL

 SIGNIFICANCE

CT Scan on Chest
and Neck

C. Laboratory Results

TEST RESULTS NORMAL RANGE CLINICAL

SIGNIFICANCE

CBC RBC: 2.9 x 10^12/L RBC: 3.8 - 5.8 A complete blood

(Hema and Coag) Hemoglobin: 88 g/L Hemoglobin: 115 - 165 count (CBC) is a
Hematocrit: 0.27 L/L Hematocrit: 0.37 - 0.47 blood test used to
09-03-22 MCV: 92.30 fL MCV: 80.00 - 100.00 evaluate your
MCH: 30.70 pg MCH: 27.00 - 32.00 overall health
MCHC: 33 g/dL MCHC: 30.0 - 35.0 and detect a wide
RDW: 13.40 % RDW: 11.50 - 14.50 range of
disorders,
WBC: 12.1 x 10^9/L WBC: 4.0 - 11.0 including
Neutrophils: 0.88 % Neutrophils: 0.40 - 0.75 anemia, infection
Lymphocyte: 0.07% Lymphocyte: 0.20 - 0.45 and leukemia. A
Monocyte: 0.05 % Monocyte: 0.00 - 0.10 complete blood
Eosinophil:0.00 % Eosinophil: 0.00 - 0.06 count test
Basophil: 0.00 % Basophil: 0.00 - 0.01 measures several
components and
Platelet Count: 500 x Platelet Count: 150 - 400 features of your
10^6/L MPV: 8.00 - 12.00 blood, including:
MPV: 8.20 fL Red blood cells,
which carry
oxygen.

Capillary HbA1c (NGSP): 6.6 % HbA1c (NGSP): 3.0 - 6.0 Capillary

Electrophoresis HbA1c (FCC): 49 % electrophoresis
mmol/mol HbA1c (FCC): 20 - 42 (CE) is the
09-03-22 eAG: 142.4 mg/dL mmol/mol primary
eAG: 68.1 - 125.5 methodology used
mg/dL for separating
and detecting
short tandem
repeat (STR)
alleles in forensic
DNA laboratories
worldwide. This
chapter examines

TSH 0.053 uIU/mL
CT Scan on Chest September 1, 2022
and Neck 1. There is clearing of the
previously noted mucosal
irregularity/thickening in
the left lateral wall of the
oropharynx, with residual
thickening noted in this
region, measuring 0.72 x
1.3 cm
2. The previously noted
enlarged, and necrotic
lymph nodes on the left
(especially the level II
node) are no longer seen.
a. Findings above denote
interval disease
regression
3. Residual thickening
the general
principles and
components of
injection,
separation, and
detection of STR
alleles using CE.
0.27 - 4.2 A TSH test is
done to find out if
your thyroid gland
is working the
way it should. It
can tell you if it's
overactive
(hyperthyroidism
) or underactive
(hypothyroidism)
. The test can also
detect a thyroid
disorder before
you have any
symptoms. If
untreated, a
thyroid disorder
can cause health
problems.
Results are considered Diagnose muscle
normal if the organs and and bone
structures being disorders, such as
examined are normal in bone tumors and
appearance. fractures.
Pinpoint the
Normal findings for the location of a
lungs include: The lung tumor, infection or
and airways are normal. blood clot. Guide
No pleural effusion or procedures such as
thickening. Heart size is surgery, biopsy
normal. No pericardial and radiation
effusion. The therapy.
mediastinum structures
have normal
configuration. Chest wall
is unremarkable.
and enhancement, with Normal findings for the
edema are seen nasopharynx include:
surrounding the left fossa asymmetry of the fossa
of Rosenmuller, with of Rosenmuller
thickening of the torus manifested as blunting or
tubarius, bilaterally; may obliteration, often with
still represent post- associated thickening of
treatment change the deglutitional. The
4. Subcentimeter medial retropharyngeal
thickening is nodes are usually not
demonstrated in the right visible.
posterior, inferolateral
aspect of the Normal findings for the
oropharynx/oropharyngea neck consists of the
l soft tissue, nasopharynx, thy and
posterolateral, and lymph nodes: Neck CT
intimately related to the images show focal or
right side of the diffuse low-attenuation
thickened uvula, swelling of all or some
measuring approximately of the soft tissues of the
0.95 x 0.98 cm; may also upper airway. The
represent post-treatment retropharyngeal nodes
change, or an are usually not visible.
inflammatory process; Thyroid CT images show
residual neoplasm, not no calcifications, no
excluded cysts, no enlargment.
5. Tympanomastoiditis,
left
6. Thyromegaly, with
nodules

August 2, 2022
1.) Abnormal
thickening of the
left nasopharynx.
A limited
comparison with
the previous
singles
representative
axial image shows
a decrease in
degree of
thickening.
2.) Subcentimeter to
top normal left
 level II lymph
nodes.
3.) Thyromegaly with
masses and
nodules.

D. Drug Study

NAME OF DRUG MECHANISM OF ACTION & INDICATION & NURSING

SIDE EFFECTS CONTRAINDICATION RESPONSIBILITIES

Mechanism of Action: Indication: Follow 10 Rights of Drug

Brand name: Administration
works by lowering your low- Is used to improve
Lipitor Rationale: To prevent
density lipoprotein (LDL) or cholesterol levels in people
Generic name:
“bad” cholesterol and raising with different types of medication errors.
your high-density lipoprotein cholesterol problems. It is
Atorvastatin Monitor cholesterol level
(HDL) or “good” cholesterol. also used to decrease your
Atorvastatin improves your risk for heart attack and and liver function through
Classification:
body’s ability to get rid of LDL stroke. It’s used together
HMG-CoA cholesterol through your liver. It blood test
with diet, weight loss, and
helps prevent cholesterol from exercise Rationale: to check
reductase
building up in your arteries .
inhibitors (statins) Clogged arteries can block flow effectivity of the medication
to heart and brain. Contradiction:
Route: Reference:
● Hypersensitivity ro https://www.medicalnewstoday.c
G-Tube atorvastatin atorvastatin-oral-tablet#alternativ
Most Side Effects:
Dosage: ● Active liver
disease or
500mg/tTAB 1 unexplained Low-fat and low-cholesterol
● Cold symptoms such as
Frequency: OD runny nose, sneezing, and transaminase diet Rationale:
coughing elevation
(8AM) ● Patient with liver Reference:https://
● Diarrhea www.medicalnewstoday.com/art
● Gas problems
atorvastatin-oral-tablet#alternativ
● Heartburn
● Joint pain CBG monitoring
● Forgetfulness
Rationale: Statins reportedly
● Confusion
● Urinary Tract Infection to increase blood sugar level.
(UTI)
Reference:
https://www.rxlist.com/consume
 n_lipitor/drugs-condition.htm

E. Nursing Care Plan

Cues Nursing Goals and Nursing Implementat Evaluation

Diagnosis Desired Interventions ions
Outcomes

Subjective: Imbalance ● Patient’s ● Assess ● Vital ● Patient’

"Nasusuka d urinary vital s s
Ako" (I Nutrition: output signs. signs urinary
want to Less Than will Rationale: asses output
vomit) Body maintain Monitor for sed will
Objective: Requireme at least fever or signs of to be maintai
nts related 30 cc/hr. dehydration withi n at
Moderate to ● Participa including n least 30
vomiting chemother te in tachycardia and norm cc/hr.
BMI of apy as specific tachypnea. al Participate in
17.3 evidenced intervent Rapid specific
by ions to respiratory rate interventions
excessive increase may indicate to increase
vomiting dietary possible dietary intake
intake. aspiration of
emesis.
● Monitor ● Outp
Intake ut of
and 1200
Output in
Rationale: 24hr
Determine fluid s
balance and the note
need for d
rehydration
intervention;
prevent
dehydration.
Decreased wet
diapers may be
a sign of
dehydration.
● Adminis ● 1L
ter IV of
Fluids D5N
Rationale: IV SS
fluids may help hook
with consistent ed to
rehydration. the
● Adminis patie
ter anti- nt
emetic ● Ond
medicati antri
ons as x
ordered admi
Rationale: niste
Treating nausea red
and preventing as
possible order
vomiting helps ed
to maintain a
certain amount
of food and
fluid intake. In
addition, timing
these
medications
with meal times
ensures at least
relief from
nausea while
eating.

● Note
character ● Vom
istics of it
nausea occu
and red
vomitus after
if medi
present. catio
Rationale: n
Timing of admi
nausea and nistr
appearance, ation
such as color, throu
consistency, and gh
amount of the
emesis, helps g-
physicians tube.
identify the Few
origin of nausea vomi
and vomiting. t was
● Identify note
precipita d.
ting ● Vom
factors iting
and occu
alleviati red
ng after
factors. medi
Rationale: catio
Paying close n
attention to was
activities close give
before or after n.
episodes of
nausea and
vomiting might
identify triggers
that can be
avoided.

● Keep
 emesis ● Basi
basin n
and oral was
care used
articles and
within wate
reach. r to
gargl
Rationale: e
Nausea often mout
goes along with h
vomiting, which after
sometimes the
occurs very patie
suddenly. nt
Therefore, it is vomi
helpful to have ted
supplies readily
at hand. In
addition, oral
care helps
remove the taste
and smell of
vomitus and
thus avoid
further
stimulation to
vomiting.

● Note the
patient’s ● Heig
weight ht is
and 150
monitor cc m
trends. and
weig
Rationale: Many ht is
patients lose 39.2
weight suddenly kg
and with
unintentionally a
during BMI
vomiting. of
Sustained 17.3
vomiting can
cause the body
to lose nutrients
that are
important for
cell
nourishment.
With the patient
not being able to
keep food in his
or her stomach
long enough to
digest and
absorb nutrients,
the body will
lose weight.
● Insert
and ● Note
maintain d
NG or prese
feeding nce
tube for of g-
enteric tube
feedings,
or
central
line for
total
parenter
al
nutrition
(TPN) if
indicated
.
Rationale: In the
presence of
severe
malnutrition
(loss of 25%–
30% body
weight in 2 mo)
or if a patient
has been NPO
for 5 days and is
unlikely to be
able to eat for
another week,
tube feeding or
 TPN may be
necessary to
meet nutritional
needs.

F. Discharge Instructions Plan/Teaching Plan

III. EVALUATION

IV. RECOMMENDATION

V. BIBLIOGRAPHY
 - Enlargement of lymph nodes
- Pagadian - cebu hospitals
- Sino doctor tumingin
- Cause that lead to bipsy
- Symptoms that lead to cancer
- Hope to survive but also in phase of acceptance
- Management of doctor: chemotherapy; radiotherapy;
- Reason for G-Tube
- Health Teaching; chemo, g tube;

References:

Almonani, M., Hassam, & Nagalli, S. (2022, January 7). Nasopharyngeal Carcinoma
(NPC, Lymphoepithelioma). NCBI. Retrieved September 11, 2022, from
https://www.ncbi.nlm.nih.gov/books/NBK558922/

George, C. K. (2019, October 24). Anatomy and Physiology of Nasopharynx - Ear, Nose &
Throat. E4ENT - Ear, Nose, Throat, Head and Neck. Retrieved September 14, 2022, from
https://www.e4ent.com/articles/anatomy-physiology-nasopharynx/