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331593011-Case-Study-Colon-Cancer.docx final
- 1. CASE STUDY (COLON CANCER) Submitted By: Tolentino, Ericka Louise D. Submitted To: Dr. Joy P. Delen, RN, MAN
- 2. CASE STUDY Name: Patient X Gender: Female Age: 52 years old Date of Birth: May 28, 1964 Address: GMA Cavite Religion: Roman Catholic Case: Stage III Colon Cancer The client continued to work. Her menstrual periods have been irregular but occasionally heavy. She experienced recent weight loss of 10 lbs over the past 6 months. A. Chief Complaint: - Weakness - Fatigue B. Medical History: The patient reported chronic constipation and hemorrhoids, mild dyspnea, exertion, and chronic arthritis in her knees. She has been monitored for hypertension with current control using diuretics. Her last mammogram 8 months ago was normal. The patient has had no screening colonoscopy. She took oral contraceptives for 10 years, but is currently not receiving hormonal therapy. C. Family History: Her mother has type 2 diabetes and her father died at age 60 of acute myocardial infarction. One brother is alive at age 61 with hypertension. D. Social History:
- 3. She is divorced with 2 children and lives alone. She has never smoked and rarely drinks alcohol. She is an avid tennis player. E. Physical Examination: She was 56 tall and weighed 128 lbs. Vital signs were as follows: BP- 130/80 mmHg, PR- 86, RR- 22, Temp.- 37. Cardiac examination was normal and present in all quadrants There was no rectal examination revealed no masses or hemorrhoids. F. Workup: She was evaluated for an underlying cause for her anemia. Her history of menstrual blood loss was not impressive, and she denied melena. The patient was referred to the Gastroenterology Department for colonoscopy, which found a mass approximately 6 cm in size located in the ascending colon and 18 inched from the anal verge, which was biopsied. An additional adenomatous mass was removed from the transverse colon. A CT scan revealed an apple core lesion in the same area of her colon as on colonoscopy. No lesions were seen in her liver. The surgeon was reluctant to perform surgery with her hematocrit at 28 %. Her lack of response to iron therapy was thought to be a result of an inflammatory state causing suppression of erythropoietin. G. Treatment Course: The patient continuing weakness and fatigue caused her daughter to take leave from her job to stay with her mother during chemotherapy. She tolerated her therapy without serious adverse events until 4th cycle. The rest of her treatment was completed without significant toxicities. H. Laboratory Result Results Hemoglobin 9.6 Hematocrit 29 Red Blood Cells 3.2 White Blood Cells 11,900
- 4. Segmenters 83% Lymphocytes 14% I. Physical Examination AREA TECHNIQUE NORMS FINDINGS Signs of distress in posture or facial expression Inspection No distress noted. The patient looks weak. Skin Color Inspection Varies from light to deep brown. Uniform Skin Color Skin Moisture Inspection Moisture in skin folds and axillae Skin is dry. Amount of body hair Inspection Variable No abnormal hairiness. Evennes of the growth, thickness or thinness of hair Inspection Evenly distributed and covers the whole scalp. Evenly distributed and covers the whole scalp. Fingernail plate shape Inspection Convex, curvature Convex Fingernail and toenail bed color Inspection Highly vascular and pink in light Pale in color Blanch test of Capilliary Refill Inspection, Palpation Promptly return of pink or usual color. Less than 4 seconds. Presence of edema and hollowness in the eye Inspection and Palpation No edema and hollowness No edema and hollowness Color, texture and presence of lesions in the palpebral conjunctiva. Inspection Pinkish in color with presence of small capilliaries;moist Pale in color Light reaction and accommodation Inspection Constrict briskly Constrict Briskly Symmetry of size and position of ears Inspection Symmetric Both auricle are symmetrical Symmetry and contour of the lips Inspection Symmetry of contour, uniform pink color Pale in Color
- 5. Gag reflex Inspection Present Present Tenderness and masses in thorax Palpation Uniform temperature; no tenderness and masses Uniform temperature; no tenderness and masses Spinal Alignment Inspection and Palpation Spine vertically aligned Spine vertically aligned Enlargement of liver or spleen Palpation No evidence of enlargement of liver or spleen No evidence of enlargement of liver or spleen Joint swelling Inspection and palpation No swelling; no redness, no pain Presence of swelling and pain. FUNCTIONAL HEALTH PATTERNS ASSESSMENT Health Perception-Health Management Pattern - The patients mother has Type 2 Diabetes and her father died because of Acute Myocardial Infarction. The patients brother has hypertension. She has never smoked and rarely drink alcohol. Nutritional-Metabolic Pattern - The patient was advised to eat high fiber and low fat foods. But she admitted that sometimes she doesnt follow it. The patient said that she cant everything she wants because of some restrictions on foods. Elimination Pattern - The client eliminates for about 1-2 times a day, has dark brown stools and sometimes she is having difficulty in eliminating. And urine 3-4 times a day. Activity-Exercise Pattern
- 6. - The patient is an avid tennis player. But when she was diagnosed with Colon Cancer, she is unable to perform any exercise at all. Sleep-Rest Pattern - She usually sleeps for about 6-8 hours a day. He cannot sleep well because sometimes she feels headache and back pain. Cognitive-Perception Pattern - The patient has hearing and eyesight problem. Sign Language is the one she is using when communicating to other people, but she can hear a little. Self-Perception, Self-Concept Pattern - The patient didnt lose her hope because of her cancer, instead she just does her best just to fight it. The patients daughters give her a reason to fight this cancer and live longer. Roles-Relationship Pattern - The patient is divorced with 2 children and lives alone. Sexuality-Reproductive System - When she and her husband were still together, they dont do sexual activities even before the detection of the clients disease. Coping-Stress Tolerance Pattern - The clients cancer has a great impact on his life. She doesnt go to work anymore since she was diagnosed with cancer because she was experiencing fatigue and weakness that caused her daughter to take a leave from her job just to stay with her during the chemotherapy. Values Belief Pattern - She is a Roman Catholic and goes to church every Sunday. God serves as a guide to her family.
- 7. Anatomy and Physiology The colon begin at the cecum, where it joins the end of the small intestine (ileum). The colon changes to rectal tissue in its last 6 inches. Because there is not a clear border between the colon and rectum, colon and rectal cancers are grouped together as colorectal. The colon is divided into 4 parts: Ascending Colon- begins at the cecum, where it joins the end of the small intestine, and travels upward along the right side of the body to the transverse colon. Transverse Colon- connects the transverse colon and the sigmoid colon and lies along the left side of the body. Sigmoid Colon- connects the descending colon and the rectum. Function: The main functions of the colon and rectum are to absorb water and nutrients from what we eat and to move food waste out of our body. The colon receives partially digested food, in a liquid form, from the small intestine. Bacterial (bowel flora) in the colon break down some materials into smaller parts. The epithelium absorbs water and nutrients. It forms the remaining waste into semi-solid material (feces or stool). The epithelium also produces mucus at the end of the digestive tract, which makes it easier for stool to pass through the colon and rectum. Sections of the colon tighten and relax (peristalsis) to move the stool to the rectum.