Capitol University College of Nursing Papillary Carcinoma of the Thyroid (A case study of RLE7,ThFS, group 12) In partial fulfillment of the requirements Of RLE 7-2 nd semester, SY 2009-2010 Presented by: Gaid, Paulo Jangaw, Wilbur Japos, Leizel Jose, Yumi Kiamco, Paula Christy Labininay, Marigold Lagamon, Robina Joyce Langam, Ronald Layam, Gerome Leones, Japhet Lequigan, katrene Presented to:
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Thyroid cancers are more often found in patients with a history of low-or-high-
dose external irradiation. Papillary tumors of the thyroid are the most common form
of thyroid cancer to result from exposure to radiation. Accounts for 85% of thyroid
cancers due to radiation exposure.
It occurs more frequently in women and presents in the 30-40 year age group
and it may also occur in children. 5%-10% of these are malignant and men have a
higher risk, even it is not common to them, of a nodule being malignant.
This case study has come to realization with the primordial aim of
understanding the disease condition in order to formulate plans of effective nursing
interventions that would help bring back the patient to the normal health status in a
gradual stage. Nursing care has been rendered to patient for one-duty shift. Hence,
evaluation of the effectivity and efficiency of such nursing interventions was not well
established.
Client’s Profile
Socio-demographic Data
Patient X is a 75-year-old, female, a Filipino citizen, from Layawan, Oroqueta City. She is religiously affiliated to Mormons religious group. She is a widow left with 9 children. Her primary language is Cebuano and is a high school graduate. She is a chronic smoker and started to smoke during her early 20’s for about 1/2 pack of cigarettes per day. She also has inherited diabetes mellitus from both sides of her parents who had a history of the disease.
Three years ago, patient X has started consultation from a doctor for complaints of swollen mass palpated in the neck and choking sensation everytime she eats. However, the mass has increased in size for the past few months and on January 20, 2010 she was diagnosed with papillary carcinoma on both lobes of the thyroid. Then on January 22, 2010 she underwent thyroidectomy and tracheostomy.
Patient X’s age is 75 years old. Her mobility status is limited due to her age. She requires special nutritional needs appropriate for her age – low fat especially low saturated fats, low in sodium and sugar. She also needs to eat vegetables and fruits.
Though Uncommon Distant spread of cancer cells may occur
Compromise other organs major function
May invade other organs
Cancer may become Systemic
Surgery:
Removal of the thyroid
If treated:
SurgeryChemotherapyRadiotherapy
Destruction of cancer cells:
ChemotherapyRadiotherapy
Abnormal Growth of mass in the right
breast
If not treated
May spread to other organs and thyroids greatly impede swallowing.
Pathologic Report: Positive for Cancer Cells
DEATH
Cancer Cells Destroyed
Etiologic Factors Actual Rationale
Age: Thyroid carcinoma is common in person at all ages with mean age of 49 years old.
Patient X is an elderly, most likely she is more prone on having thyroid cancer age75 years old.
Elderly person tend to be more at risk on developing thyroid cancer
Gender: Recent studies found out that the female-to-male ratio is almost 3:1 related in patients’ age which older than 45 years.
Patient X’s gender is female
Women are three times more prone to develop cancer than men.
Lifestyle: cigarette smoking mostly increase the risk of developing thyroid disorders/cancer
Patient X has been smoking for more than 30 years
Foreign studies found out that smoking greatly increase the risk of developing thyroid disorders. One component of tobacco smoke is cyanide, which is converted to thiocyanate, which acts as an anti-thyroid agent, directly inhibiting iodide uptake and hormone synthesis.
Predisposing Factors (figure A.)
Precipitating Factors (figure B.)
Etiologic Factors Actual Rationale
Developing abnormal buildup of mass in the front upper neck.
Patient X experience an enlargement of her neck and difficulty in swallowing
3 months prior to admission patient X experience chocking when swallowing food even in small amount and notices build up of mass in the neck.
Laboratory and Tests Results
Microbiology Gram Stain Report
February 5, 2010
Result: No microorganism seen
Polymorphonuclear cells: Moderate
Epithelial cells: Few
Interpretation:
Neutrophils or polymorphonuclear cells (Polys) fight bacterial infections. They normally account for 55% to 70% of WBCs. If you have a very low count, you could get a bacterial infection. This condition is called neutropenia. Advanced HIV disease can cause neutropenia. So can some medications including ganciclovir, a drug used to treat cytomegalovirus and the anti-HIV drug.
Clinical Chemistry
February 4, 2010
Ionized Calcium
Result: 0.91 mmol/L
Reference range: 1.12 – 1.32 mmol/L
Interpretation:
Ionized calcium is vitally important in blood coagulation, nerve conduction, neuromuscular transmission and in muscle contraction. Decreased ionized calcium (hypocalcemia) often results in cramps (tetany), reduced cardiac stroke work and depressed left ventricular function. Prolonged hypocalcemia may result in bone demineralization (osteoporosis) which can lead to spontaneous fractures.
January 25, 2010
Final Pathological Report:
Papillary Carcinoma, both lobes
Fibro-collagenous Tissue, Specimen B
Gross and Microscopic Description:
Received two specimens:
a. A specimen consists of the thyroid gland the left and right lobes measure 10.2 x 7.5 x 4 and 6.8 x 7 x 3 cm. The isthmus measure 3 x 0.2 cm. Cut sections of the left and right lobe show ill defined fan mass, 8 x 4.7 and 3.2 x 1.8 cm, surrounded by meats and fan parenchyma.
b. Specimen consists of an irregular strip of grayish white rubbery tissue fragment measuring 0.3 cm. Black all.
Microscopic Description:
Microsections of both lobes show thyroid tissues. There are solid sheets tumor cells, round to avoid with nuclear clearing. Fibrous tissues separate sheets of tumor cells.
Microsection of specimen b show fibro-collagenous tissues. There is no evidence of malignancy.
Interpretation:
Papillary carcinoma: About 8 of 10 thyroid cancers are papillary carcinomas (also called papillary cancers or papillary adenocarcinomas). Papillary carcinomas typically grow very slowly. Usually they develop in only one lobe of the thyroid gland, but sometimes they occur in both lobes. Even though they grow slowly, papillary carcinomas often spread to the lymph nodes in the neck. But most of the time, this can be successfully treated and is rarely fatal.
Several different variants (subtypes) of papillary carcinoma can be recognized under the microscope. Of these, the follicular variant (also calledmixed papillary-follicular variant) occurs most often. The usual form of papillary carcinoma and the follicular variant have the same outlook for survival (prognosis), and treatment is the same for both. Other variants of papillary carcinoma (columnar, tall cell, diffuse sclerosis) are not as common and tend to grow and spread more quickly
HEMOGLUCOTEST
Normal Values: Before Meals: 90-130 mg/dl
After Meals: less than 180 mg/dl
Results
January 27, 2010 227 mg/dl
January 31, 2010 243 mg/dl
February 2, 2010 104 mg /dl----------7:50 pm
February 4, 2010 183 mg /dl ----------7:30 pm
February 4, 2010 107 mg/dl ----------11:30 am
February 5, 2010 231 mg/dl
Interpretation:
Healthy blood sugar level ranges
Blood sugar levels over 200 mg/dL (mg/dL = milligrams of glucose per deciliter of blood) or under 60 mg/dL are considered unhealthy. High blood sugar levels (above 200 mg/dL) may be a sign of inadequate levels of insulin, caused by diabetes medication, overeating, lack of exercise, or other factors. Low blood sugar levels (below 60 mg/dL) may be a caused by taking too much insulin, skipping or postponing a meal, over-exercising, excessive alcohol consumption, or other factors.
The following are the most common symptoms of hyperglycemia (high blood sugar). However, each individual may experience symptoms differently. Symptoms may include rapid weight loss, feeling sick, thirst, vomiting, fatigue, blurred vision and fainting. The following are the most common symptoms of hypoglycemia (low blood sugar). However, each individual may experience symptoms differently. Symptoms may include: hunger, fatigue and shakiness.
Creatinine
Normal range: 0.6 - 1.2 mg/dL
Sodium
Normal range: 135 - 145 mEq/L
BUN
Normal range: 5 – 35
Potassium
Normal range: 3.5 - 5.0 mEq/L
Decrease in serum potassium is seen usually in states characterized by excess K+ loss, such as in vomiting, diarrhea, villous adenoma of the colorectum, certain renal tubular defects, hypercorticoidism, etc. Redistribution hypokalemia is seen in glucose/insulin therapy, alkalosis (where serum K+ is lost into cells and into urine), and familial periodic paralysis. Drugs causing hypokalemia include amphotericin, carbenicillin, carbenoxolone, corticosteroids, diuretics, licorice, salicylates, and ticarcillin.
Drug Study
Generic Name: atorvastatin calcium
Brand Name: Lipitor
Classification: Antilipemics
Dosage: 40 mg
Route: PO
Frequency: OD @ HS
Indications and dosages:
- Adjunct to diet to reduce LDL and total cholesterol, apolipoprotein B and triglyceride levels in patients with primary hypercholesterolemia and mixed dyslipidemia; primary dysbetelipoproteinemia that doesn’t respond adequately to diet; adjunct to diet for elevated triglyceride levels.
- Alone or as adjunct to lipid-lowering treatments such as LDL apheresis in patients with homozygous familial hypercholesterolemia.
Mechanism action:
- Inhibits 3-hydroxy-3-methyglutaryl coenzyme A (HMG-CoA) reductase, which is an early (and rate-limiting) step in cholesterol biosynthesis.
- Contraindicated in patients hypersensitive to drug and in those with active liver disease or unexplained persistent elevations of transaminase levels. Also contraindicated in pregnant and breast-feeding women and in women of childbearing potential.
Nursing Responsibilities:
- Remember 10 rights of drug administration
- Drug should be withheld or discontinued in patients at risk for renal failure, in serious, acute conditions that suggest myopathy, and severe acute infection, hypotension and uncontrolled seizures.
- Start drug therapy only after diet and other nonpharmacologic treatments prove ineffective. Patient should follow a standard low-cholesterol diet before and during therapy.
- Drug maybe given as a single dose at any time of the day, with or without food.
- Warn patient to avoid alcohol.
- Advise patient that drug can be taken at any time of the day, without regard to meals.
Generic name: budesonide
Brand name: Pulmicort turbuhaler
Classification: Respiratory tract drugs
Dosage: ½ neb
Route: via tracheostomy
Frequency: tid
Indications and Dosages:
-Prophylactic therapy in maintenance treatment of asthma.
Action:
- Anti-inflammatory corticosteroid that exhibits potent glucocorticoid activity and weak mineralocorticoid activity. Have a wide range of inhibitory activity against such cell types as mast cells and macrophages and mediator involved in allergic and non-allergic inflammation.
- Contraindicated in patients hypersensitive to drug and in those with status asthmaticus or other acute asthma episodes.
Nursing Responsibilities:
- Remember 10 rights of drug administration.
- If bronchospasm occurs after using budesonide, stop therapy and treat with bronchodilator
- Improve lung function has been observed within 24 hours of starting budesonide treatment, although maximum benefit may not achieved for 1 – 2 weeks or longer.
- In rare cases, inhaled corticosteroids have been linked to increased intraocular pressure and cataract development. If local irritation occurs, drug may be discontinued.
Generic name: calcitriol
Brand name: Rocaltrol
Classification: Parathyroid like drugs
Dosage: .25 mg
Route: PO
Frequency: bid
Mechanism of action:
- Vitamin D analogue that stimulates calcium absorption from the GI tract and promotes movement of calcium from bone to blood.
Indications:
- hypocalcemia in patients undergoing long term dialysis.
- hypoparathyroidism, pseudohypoparathyroidism
- management of secondary hyperparathyroidism and resulting metabolic bone disease in predialysis patient.
Adverse reactions:
- none reported
Contraindications:
- Contraindicated in patients with hypercalcemia or vit. D toxicity. Withhold all preparations containing vit. D.
Nursing responsibilities:
- Use cautiously in patients receiving cardiac glycosides and in those with hyperparathyroidism.
- Protect drug from direct light.
- Tell patient to immediately report symptoms of vit. D intoxication: weakness, nausea, vomiting, dry mouth, constipation, muscle or bone pain, or metallic taste.
- Instruct patient to adhere to diet and calcium supplementation and to avoid unapproved OTC drugs and magnesium containing antacids.
Generic name: albumin 25%
Brand name: Albutein 25%
Classification: Blood derivatives or hematologic drugs
Dosage: 100 ml
Route: IVTT
Frequency: od
Mechanism of action:
- Albumin 25% provides intravascular oncotic pressure in a 5:1 ratio, causing a fluid shift from interstitial spaces to the circulation and slightly increasing plasma protein level.
Indications:
- hypovolemic shock
- hypoproteinemia
- hyperbilirubinemia
Adverse reactions:
- CNS: headache
- CV: vascular overload after rapid infusion, hypotension, tachycardia
- GI: increase salivation, nausea, vomiting
- Musculoskeletal: back pain,
- Respiratory: dyspnea, pulmonary edema
- Skin: urticaria, rash
- Others: chills, fever
Contraindications:
- Contraindicated in patient hypersensitive to drug and in those with severe anemia or cardiac failure.
Nursing responsibilities:
- Remember 10 rights of drug administration.
- Use with extreme caution in patients with hypertension, and pulmonary edema.
- Monitor vital signs carefully.
- Monitor fluid intake and output.
- Follow storage instructions on bottle freezing may cause bottle to break.
- Tell patient to report adverse reactions promptly
Generic name: methyprednisolone sodium
Brand name: Solu-Medrol
Classification: Hormonal drugs
Dosage: 50mg
Route: IVTT
Frequency: TID
Mechanism of action:
- Not clearly defined. Decreases inflammation, mainly by stabilizing leukocyte lysosomal membrane; suppresses immune response; stimulates bone marrow; and influences protein, fat, and carbohydrate metabolism.
Indications:
- severe inflammation or immunosuppression- shock
Adverse reactions:
CNS: insomnia, seizure, headache
CV: hypertension, edema, thrombophlebitis, heart failure, cardiac arrest, circulatory collapse after rapid use of large IV doses
EENT: cataracts, glaucoma
GI: peptic ulceration, GI irritation, nausea, vomiting
After prolonged use, sudden withdrawal maybe fatal.
Contraindications:
- contraindicated in patient hypersensitive to drug or its ingredients and in those with systemic fungal infection; also contraindicated in premature infants
Nursing responsibilities:
- Remember 10 rights of drug administration.- Determine whether patient is sensitive to other corticosteroid.- For better results and less toxicity, give once or daily dose in the morning.- Give oral dose with food when possible.- Watch for depression or psychotic episodes especially in high dose therapy.- Unless contraindicated, give low-sodium diet that’s high in potassium and
protein.- Gradually reduce dosage after long term therapy.- Tell patient not to stop drug abruptly or without prescriber’s consent.
Generic name: meropenem trihydrate
Brand name: Meronem
Classification: Anti-bacterial
Dosage: 500mg
Route: IVTT
Frequency: QID
Mechanism of action:
- Exerts its bactericidal action by interfering with vital bacterial cell wall synthesis. The ease with which it penetrates bactericidal cells, its high level of stability to all serine B-lactamase and its marked affinity for the penicillin binding proteins explain the potent bactericidal activity against broad spectrum of aerobia and anaerobic bacteria.