DIPOLOG MEDICAL CENTER COLLEGE FOUNDATION INC.

College of Nursing

A
CASE STUDY
OF
GASTRIC CANCER

Submitted by:
SHARMAINE S. CAGANG
BSN III - KING

Submitted to:
MR. HAROLD S. NABOR, USRN
INSTRUCTOR
 CONTENTS

A. Introduction

B. Terminologies

C. Anatomy and Physiology

D. Pathophysiology

E. Nursing Care Plan

F. Discharge Instructions (Methods) Style

G. Drug Study

H. Readings r/t Digestive cases / Articles Summary and Reaction

I. General Evaluation including Laboratory / Diagnostic Tests

 A. INTRODUCTION
Description

 It is also called malignant tumor of the stomach.

 It is usually an adenocarcinoma.
 It spreads rapidly to the lungs, lymph nodes, and liver.
 Risk factors include chronic atrophic gastritis with intestinal metaplasia;
pernicious anemia or having had gastric resections (greater than 15 years
prior); and adenomatous polyps.
 This cancer is most common in men older than age 40 and in blacks.
 Complications are hemorrhage and dumping syndrome from surgery or
widespread metastasis and death.

Causes/ Risk Factors

No one knows why some people develop stomach cancer and others don’t. The
number of people affected varies widely between different countries. For example,
stomach cancer is far more common in Japan than in the UK. There is also evidence
that people from poorer backgrounds are at increased risk.

There are a many other factors that increase the risk of developing stomach
cancer.
 Age. Stomach cancer is most common around the age of 60. It’s rare
under the age of 40.
 Gender. Men are around twice as likely to develop stomach cancer as
women.
 Helicobacter pylori infection. These bacteria live in the stomach lining
of many people, and don’t usually cause any symptoms. However, the
infection sometimes causes inflammation of the stomach lining (gastritis),
indigestion and stomach ulcers. It is known to increase the risk of stomach
cancer.
 Diet. A diet high in salt and foods that are smoked or cured may increase
the risk of stomach cancer. In particular, certain food preservative
 chemicals known as nitrosamines, which are found cured meats such as
bacon and ham, may increase your chance of developing stomach cancer.
 Family history. Some people inherit an increased risk of developing
stomach cancer.
 Type A blood group. Some research indicates that people who have
type A blood are at higher risk of developing stomach cancer.
 Smoking. When you smoke, you swallow small amounts of tobacco
smoke, which increases your risk of getting stomach cancer.
 Atrophic gastritis. This condition causes the lining of the stomach to
waste away. It has also been linked with an increased risk of stomach
cancer.
 Pernicious anaemia. This is type of anaemia raises your risk of stomach
cancer.

Assessment
 Most often, the patient presents with the same symptoms as gastric ulcer.
Later, evaluation shows the lesion to be malignant.
 Gastric fullness (early satiety), dyspepsia lasting more than 4 weeks,
progressive loss of appetite are initial symptoms.
 Stool samples are positive for occult blood.
 Vomiting may occur and may have coffee-ground appearance.
 Later manifestations include pain in black or epigastric area (often induced by
eating, relieved by antacids or vomiting); weight loss; hemorrhage; gastric
obstruction.
 B. TERMINOLOGIES

Atrophic gastritis - a histopathologic entity characterized by chronic inflammation of

the gastric mucosa with loss of the gastric glandular cells and replacement by intestinal-
type epithelium, pyloric-type glands, and fibrous tissue.

Dyspepsia - also known as indigestion, refers to discomfort or pain that occurs in the
upper abdomen, often after eating or drinking.

Dysplasia - A term used to describe the presence of abnormal cells within a tissue or
organ.

Gastritis - a condition that inflames the stomach lining (the mucosa), causing belly pain,
indigestion (dyspepsia), bloating and nausea.

Intestinal Metaplasia - a condition in which the cells that create the lining of your
stomach are changed or replaced. 

Metaplasia - the replacement of one differentiated somatic cell type with another
differentiated somatic cell type in the same tissue. 

Pernicious anemia - a type of vitamin B12 anemia.

 C. ANATOMY AND PHYSIOLOGY

Stomach
 The stomach is a muscular, J-shaped organ in the upper part of the abdomen. It
is part of the digestive system, which extends from the mouth to the anus. The
size of the stomach varies from person to person, and from meal to meal.
Structure
The stomach is part of the digestive system and is connected to the:
 Esophagus – a tube-like organ that connects the mouth and throat to the
stomach. The area where the esophagus joins the stomach is called the
gastroesophageal (GE) junction.
 Small intestine (small bowel) – a long tube-like organ that extends from the
stomach to the colon (large intestine or large bowel). The first part of the
small intestine is called the duodenum, and it is this part that is connected to
the stomach.
  The stomach is surrounded by a large number of lymph nodes.

Regions of the stomach

The stomach is divided into 5 regions:
 The cardia is the first part of the stomach below the esophagus. It contains
the cardiac sphincter, which is a thin ring of muscle that helps to prevent
stomach contents from going back up into the esophagus.
 The fundus is the rounded area that lies to the left of the cardia and below
the diaphragm
 The body is the largest and main part of the stomach. This is where food is
mixed and starts to break down.
 The antrum is the lower part of the stomach. The antrum holds the broken-
down food until it is ready to be released into the small intestine. It is
sometimes called the pyloric antrum.
 The pylorus is the part of the stomach that connects to the small intestine.
This region includes the pyloric sphincter, which is a thick ring of muscle that
acts as a valve to control the emptying of stomach contents (chyme) into the
duodenum (first part of the small intestine). The pyloric sphincter also
prevents the contents of the duodenum from going back into the stomach.

Layers of the stomach wall

 The mucosa (mucous membrane) is the inner lining of the stomach. When the
stomach is empty the mucosa has a ridged appearance. These ridges (rugae)
flatten out as the stomach fills with food.
 The next layer that covers the mucosa is the submucosa. It is made up of
connective tissue that contains larger blood and lymph vessels, nerve cells and
fibres.
 The muscularis propria (or muscularis externa) is the next layer that covers
the submucosa. It is the main muscle of the stomach and is made up of 3 layers
of muscle.
  The serosa is the fibrous membrane that covers the outside of the stomach. The
serosa of the stomach is also called the visceral peritoneum

Function
 The stomach has 3 main functions:
o temporary storage for food, which passes from the esophagus to the stomach
where it is held for 2 hours or longer
o mixing and breakdown of food by contraction and relaxation of the muscle
layers in the stomach
o digestion of food
 The mucosa contains specialized cells and glands that produce hydrochloric acid
and digestive enzymes to help digest food. The mucosa in the cardiac and
pyloric regions of the stomach release mucus that helps protect the lining of the
stomach from the acid produced for digestion. Other specialized cells in the
mucosa of the pylorus release the hormone gastrin into the blood. Gastrin helps
to stimulate the release of acid and enzymes from the mucosa. Gastrin also
helps the muscles of the stomach to start contracting.
 Food is broken down into a thick, acidic, soupy mixture called chyme. The pyloric
sphincter relaxes once chyme formation is complete. Chyme then passes into the
duodenum. The duodenum plays a big role in absorption of the food we eat. The
stomach does not play a big role in absorption of food. It only absorbs water,
alcohol and some drugs.

.
 D. PATHOPHYSIOLOGY

NORMAL

DIET FACTORS
(LOW IN VITAMIN C & E, H. PYLORI INFECTION
HIGH SALT DIET)

CHRONIC SUPERFICIAL GASTRITIS

ATROPHIC GASTRITIS

INTESTINAL METAPLASIA

DYSPLASIA

CANCER
 E. NURSING CARE PLAN
ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION
1. Review patient’s and 1. Clarifies patient’s
Subjective: Fear may be After 8 hours of SO’s previous perceptions; assists in After 8 hours of
related to nursing experience with cancer. identification of fear(s) and nursing interventions,
“ threat to or interventions, the Determine what the misconceptions based on the goal was met. The
change in doctor has told patient diagnosis and experience
“Wala
patient will patient was able to
“ health or display and what conclusion with cancer. display appropriate
socioeconomic appropriate patient has reached. 2. Provides opportunity to range of feelings and
naman status, role
functioning,
range of feelings
and lessened
2. Encourage patient to
share thoughts and
examine realistic fears and
misconceptions about
lessened fear.
interaction feelings. diagnosis.
akong patterns
possibly
fear. 3. Provide open
environment in which
3. Helps patient feel
accepted in present

proble evidence by
Expressed
patient feels safe to
discuss feelings or to
condition without feeling
judged, and promotes
concerns refrain from talking. sense of dignity and control.
ma sa regarding
changes in life
4. Maintain frequent
contact with patient. Talk
4. Provides assurance that
patient is not alone or

pagpap events and

feelings of
with and touch patient as
appropriate.
rejected; conveys respect
for and acceptance of the
helplessness, 5. Be aware of effects of person, fostering trust.
aospital hopelessness,
inadequacy.
isolation on patient when
required by
5. Sensory deprivation may
result when sufficient

. Kaya immunosuppression or
radiation implant. Limit
stimulation is not available
and may intensify feelings
use of isolation clothing of anxiety, fear and
nga ako and masks as possible.
6. Assist patient and SO
alienation.
6. Coping skills are often

nagpap in recognizing and

clarifying fears to begin
stressed after diagnosis and
during different phases of
developing coping treatment. Support and
aospital
strategies for dealing counseling are often
with these fears. necessary to enable
7. Provide accurate, individual to recognize and
para consistent information
regarding
deal with fear and to realize
that control and coping

magam
diagnosis and prognosis. strategies are available.
Avoid arguing about 7. Can reduce anxiety and
patient’s enable patient to make
ot perceptions of situation.
8. Permit expressions of
decisions and choices
based on realities.
anger, fear, despair 8. Acceptance of feelings
Objective: without confrontation. allows patient to begin to
Give information that deal with situation.
feelings are normal and 9. Patient may use defense
are to be appropriately mechanism of denial and
expressed. express hope that diagnosis
9. Be alert to signs of is inaccurate. Feelings of
denial and depression guilt, spiritual distress,
(withdrawal, anger, physical symptoms, or lack
inappropriate remarks). of cure may cause patient to
Determine presence of become withdrawn and
suicidal ideation and believe that suicide is a
assess potential on a viable alternative.
scale of 1–10. 10. Allows for better
10. Provide reliable and interpersonal interaction
consistent information and reduction of anxiety and
and support for SO. fear.
11. Include SO as 11. Provides a support
indicated or patient system for patient and
desires when allows SO to be involved
major decisions are to appropriately.
be made.
 F. DISCHARGE INSTRUCTIONS (METHODS) STYLE

Medicines:

 You may need any of the following:

o Antinausea medicine may be given to calm your stomach and prevent
vomiting.
o Prescription pain medicine may be given. Ask your healthcare provider
how to take this medicine safely. Some prescription pain medicines
contain acetaminophen. Do not take other medicines that contain
acetaminophen without talking to your healthcare provider. Too much
acetaminophen may cause liver damage. Prescription pain medicine may
cause constipation. Ask your healthcare provider how to prevent or treat
constipation.
o Blood thinners help prevent blood clots. Clots can cause strokes, heart
attacks, and death. The following are general safety guidelines to follow
while you are taking a blood thinner:
o Watch for bleeding and bruising while you take blood thinners. Watch for
bleeding from your gums or nose. Watch for blood in your urine and bowel
movements. Use a soft washcloth on your skin, and a soft toothbrush to
brush your teeth. This can keep your skin and gums from bleeding. If you
shave, use an electric shaver. Do not play contact sports.
o Tell your dentist and other healthcare providers that you take a blood
thinner. Wear a bracelet or necklace that says you take this medicine.
o Do not start or stop any other medicines unless your healthcare provider
tells you to. Many medicines cannot be used with blood thinners.
o Take your blood thinner exactly as prescribed by your healthcare provider.
Do not skip does or take less than prescribed. Tell your provider right
away if you forget to take your blood thinner, or if you take too much.
o Warfarin is a blood thinner that you may need to take. The following are
things you should be aware of if you take warfarin:
 o Foods and medicines can affect the amount of warfarin in your blood. Do
not make major changes to your diet while you take warfarin. Warfarin
works best when you eat about the same amount of vitamin K every day.
Vitamin K is found in green leafy vegetables and certain other foods. Ask
for more information about what to eat when you are taking warfarin.
o You will need to see your healthcare provider for follow-up visits when you
are on warfarin. You will need regular blood tests. These tests are used to
decide how much medicine you need.
 Take your medicine as directed. Contact your healthcare provider if you think
your medicine is not helping or if you have side effects. Tell him or her if you are
allergic to any medicine. Keep a list of the medicines, vitamins, and herbs you
take. Include the amounts, and when and why you take them. Bring the list or the
pill bottles to follow-up visits. Carry your medicine list with you in case of an
emergency.

Do not smoke:
 Nicotine can damage blood vessels and make it more difficult to manage
stomach cancer. Smoking also increases your risk for new or returning cancer
and delays healing after treatment. Do not use e-cigarettes or smokeless tobacco
in place of cigarettes or to help you quit. They still contain nicotine. Ask your
healthcare provider for information if you currently smoke and need help quitting.

Do not drink alcohol:

 Alcohol can cause more stomach damage.

Nutrition:

 If you had surgery to remove part of your stomach, you may need to follow a
special diet. This may decrease symptoms, such as dumping syndrome (food
passing too quickly through your stomach and into your intestines). A dietitian
may work with you to help reduce symptoms.
Drink liquids as directed:
 Ask how much liquid to drink each day and which liquids are best for you. Drink
extra liquids to prevent dehydration. You will also need to replace fluid if you are
vomiting or have diarrhea from cancer treatments.

Exercise as directed:
 Exercise can help increase your energy level and appetite. Ask your healthcare
provider how much exercise you need and which exercises are best for you.

Call your local emergency number for any of the following:

 You suddenly feel lightheaded and short of breath.
 You have chest pain when you take a deep breath or cough.
 You cough up blood.

Seek care immediately if:

 Your arm or leg feels warm, tender, and painful. It may look swollen and red.
 You are vomiting and cannot keep food or liquids down.
 You are dizzy or feel confused.

Call your doctor or oncologist if:

 Your pain is worse or does not go away after you take pain medicine.
 You have a fever.
 You have questions or concerns about your condition or care.

Follow up with your doctor or oncologist as directed:

 You will need to see your oncologist for ongoing tests and treatment. Write down
your questions so you remember to ask them during your visits.
 G. DRUG STUDY

Nursing
Drug Mechanism of Action Indications Contraindications Side effects
considerations
Generic Name: Ramucirumab binds with CYRAMZA®, as a  Anticoagulant Single agent
high affinity to the single agent or in therapy,  Hypertension
Ramucirumab
extracellular domain of combination with bleeding, GI  Diarrhea
Brand Name: vascular endothelial paclitaxel, is bleeding, GI Combination therapy
growth factor receptor 2 indicated for the perforation  Fatigue/asthenia
Cyramza
(VEGFR2; kinase insert treatment of  Impaired wound  Neutropenia
Classification: domain-containing patients with healing, surgery  Neutropenia,
receptor; KDR), advanced or  Infusion-related Grade 3-4
Monoclonal
preventing the binding of metastatic, gastric reactions  Diarrhea
antibody ligands VEGF-A, VEGF- or gastro-  Cardiac arrest,  Epistaxis
C, and VEGF-D. As a esophageal myocardial  Peripheral edema
result, ramucirumab junction (GEJ) infarction,  Hypertension
inhibits ligand- adenocarcinoma stroke  Stomatitis
stimuluated activation of with disease  Hypertension  Proteinuria
VEGFR2, inhibiting progression on or  Biliary cirrhosis, Hypertension,
ligand-induced after prior hepatic disease Grade 3-4
proliferation, and fluoropyrimidine-or  Thrombocytopenia
 Human anti-
migration of human platinum-  Fatigue/asthenia,
human antibody
endothelial cells. containing Grade 3-4
(HAHA)
Ramucirumab inhibited chemotherapy.  Hypoalbuminemia
 Proteinuria,
angiogenesis in an in
renal disease
vivo animal model.
Ramucirumab works  Breast-feeding
differently than  Encephalopathy
bevacizumab, another  Hypothyroidism,
VEGF inhibitor, in that thyroid disease
bevacizumab binds to  Pregnancy
the ligand, VEGF,  Contraception
preventing it from requirements,
binding to infertility,
VEGFR2/KDR; pregnancy
bevacizumab also testing,
 decreases VEGF levels reproductive
after binding. risk
Ramucirumab binds to
VEGF2, preventing the
VEGF ligands from
binding, and does not
affect initial levels of
VEGF. The mechanism
of binding to VEGFR2
rather than VEGF may
also induce less
resistance, since
endothelial cells are
genetically stable.

Mechanism of Nursing
Drug Indications Contraindications Side effects
Action considerations
Generic Name: Trastuzumab binds to  Indicated, in Concurrent Body as a Whole: Pain,  Lab tests:
the extracellular combination with administration of asthenia, fever, chills, flu Periodically monitor
Trastuzumab
juxtamembrane cisplatin and anthracycline or syndrome, allergic CBC with differential,
Brand Name: domain of HER2 and capecitabine or 5- radiation; lactation reaction, bone pain, platelet count, and
inhibits the fluorouracil, for the during and for 6 mo arthralgia, hypersensitivity Hgb and Hct.
Herceptin
proliferation and treatment of patients following (anaphylaxis, urticaria,  Monitor for chills and
Classification: survival of HER2- with HER2- administration of bronchospasm, fever during the first
dependent tumors. It overexpressing trastuzumab. angioedema, or IV infusion; these
Antineoplastics,
is approved by the metastatic gastric or hypotension), increased adverse events
Anti-HER2 Food and Drug gastroesophageal incidence of infections, usually respond to
Administration (FDA) junction infusion reaction (chills, prompt treatment
for patients with adenocarcinoma who fever, nausea, vomiting, without the need to
invasive breast have not received pain, rigors, headache, discontinue the
cancers that prior treatment for dizziness, dyspnea, infusion. Notify
overexpress HER2. metastatic disease. hypotension, rash).  physician
CNS: Headache, immediately.
insomnia, dizziness,  Monitor carefully
paresthesias, depression, cardiovascular status
peripheral neuritis, at baseline and
neuropathy.  throughout course of
CV: CHF, cardiac therapy, assessing
dysfunction (dyspnea, for S&S of heart
cough, paroxysmal failure (e.g.,
nocturnal dyspnea, dyspnea, increased
peripheral edema, S3 cough, PND, edema,
gallop, reduced ejection S3 gallop). Those
fraction), tachycardia, with preexisting
edema, cardiotoxicity.  cardiac dysfunction
GI: Diarrhea, abdominal are at high risk for
pain, nausea, cardiotoxicity.
vomiting, anorexia. 
Hematologic: Anemia,
leukopenia. 
Respiratory: Cough,
dyspnea, rhinitis,
pharyngitis, sinusitis. 
Skin: Rash, herpes
simplex, acne.
H. READINGS R/T DIGESTIVE CASES / ARTICLES SUMMARY AND
REACTIONS
 I. GENERAL EVALUATION INCLUDING LABORATORY OR DIAGNOSTIC
TESTS

In addition to a physical examination, the following tests may be used to diagnose

stomach cancer:

 Biopsy. A biopsy is the removal of a small amount of tissue for examination

under a microscope. Other tests can suggest that cancer is present, but only a
biopsy can make a definite diagnosis. A pathologist then analyzes the sample(s).
A pathologist is a doctor who specializes in interpreting laboratory tests and
evaluating cells, tissues, and organs to diagnose disease.
 Molecular testing of the tumor. Your doctor may recommend running
laboratory tests on a tumor sample to identify specific genes, proteins, and other
factors unique to the tumor. Results of these tests can help determine your
treatment options.
For stomach cancer, testing may be done for PD-L1 and high microsatellite
instability (MSI-H), which may also be called a mismatch repair deficiency.
Testing can also be done to determine if the tumor is making too much of a
protein called human epidermal growth factor receptor 2 (HER2), particularly if
the cancer is more advanced. The results of these tests help doctors find out if
immunotherapy is a treatment option.
 Endoscopy. An endoscopy allows the doctor to see the inside of the body with
a thin, lighted, flexible tube called a gastroscope or endoscope. The person may
be sedated as the tube is inserted through the mouth, down the esophagus, and
into the stomach and small bowel. Sedation is giving medication to become more
relaxed, calm, or sleepy. The doctor can remove a sample of tissue as a biopsy
during an endoscopy and check it for signs of cancer.
 Endoscopic ultrasound. This test is similar to an endoscopy, but the
gastroscope has a small ultrasound probe on the end. An ultrasound uses
sound waves to create a picture of the internal organs. An ultrasound image of
the stomach wall helps doctors determine how far the cancer has spread into the
 stomach and nearby lymph nodes, tissue, and organs, such as the liver or
adrenal glands.
 X-ray. An x-ray is a way to create a picture of the structures inside of the body
using a small amount of radiation.
 Barium swallow. In a barium swallow, a person swallows a liquid containing
barium, and a series of x-rays are taken. Barium coats the lining of the
esophagus, stomach, and intestines, so tumors or other abnormalities are easier
to see on the x-ray.
 Computed tomography (CT or CAT) scan. A CT scan takes pictures of the
inside of the body using x-rays taken from different angles. A computer combines
these pictures into a detailed, 3-dimensional image that shows any abnormalities
or tumors. A CT scan can be used to measure the tumor’s size. Sometimes, a
special dye called a contrast medium is given before the scan to provide better
detail on the image. This dye is usually given both as a liquid to swallow and an
injection into a patient's vein.
 Magnetic resonance imaging (MRI). An MRI uses magnetic fields, not x-rays,
to produce detailed images of the body. MRI can be used to measure the tumor’s
size. A special dye called a contrast medium is given before the scan to create a
clearer picture. This dye is usually injected into a patient’s vein.
 Positron emission tomography (PET) or PET-CT scan. A PET scan is usually
combined with a CT scan (see above), called a PET-CT scan. However, you
may hear your doctor refer to this procedure just as a PET scan. A PET scan is a
way to create pictures of organs and tissues inside the body. A small amount of a
radioactive sugar substance is injected into the patient’s body. This sugar
substance is taken up by cells that use the most energy. Because cancer tends
to use energy actively, it absorbs more of the radioactive substance. A scanner
then detects this substance to produce images of the inside of the body.
 Laparoscopy. A laparoscopy is a minor surgery in which the surgeon inserts a
thin, lighted, flexible tube called a laparoscope into the abdominal cavity. It is
used to find out if the cancer has spread to the lining of the abdominal cavity or
liver. A CT or PET scan cannot often find cancer that has spread to these areas.