Nasopharyngeal Carcinoma

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Nasopharyngeal Carcinoma

• Case Study

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Demographic Data

• CASE NO 116
• NAME Mr. M
• AGE 46 yrs old
• SEX Male
• DIAGNOSIS Nasopharyngeal
  Carcinoma

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Physical Assessment
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Vital Signs

• BP- 120/70 mmhg
• RR- 32/min
• PR- 72/min
• Temp- 36.8C

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Integument

• Skin allergy noted at upper extremities
• With good skin turgor
• With capillary refill test
• (1-2secs)

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Head

• No palpable lesion on the head
• With right side facial numbness
• Always complaining of headache

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Eyes

• Pale palpebral conjunctiva
• PERRLA (Pupils Equally Round and Reactive to
  Light Accommodation)
• Sometimes experienced blurring of vision and
  light sensitivity

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Ears

• Symmetrical in shape and size
• With occasional ear pain
• Diminished hearing
• Tinnitus noted at
• times

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Nose

• with epistaxis
• with right nasal obstruction
• with mass, reddish in color seen through rigid
  endoscope
• cough and cold noted, whitish secretions

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Mouth

• Hard and soft palate grayish in color.
• Difficulty in uttering words noted
• Mouth breathing

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Neck and Throat

• With painless, enlarged lymph nodes in the neck
• Sore throat noted

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Respiratory/ Chest

• Chest is symmetric
• Use of accessory muscles when breathing
• Crackles noted both lung fields

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Extremities

• No edema found on both legs
• No lesions noted

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Medical History
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Past Medical History

• No major medical problems
• Common colds- treated with water therapy
• Ignored sneezing

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Socio-economic Lifestyle

• Sedentary lifestyle
• Smoking 1 pack in a day
• No restrictions for food- Filipino foods
• Shoe factory worker store keeper(construction
  materials) store keeper (KSA) store
  keeper(hosp)

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Family History
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Legend

• - father
• mother
• aunt
• cousin

• lung cancer
• NPC
• prostate cancer

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Fathers side Mothers side
1st
2nd
3rd
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• Present Medical History

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1st visit- (July 24, 2010)

• Dr. H.
• Chief complaint- nose bleeding
• Nasopharyngoscopy done
• Dx- deviated nasal septum
• Advised for CT scan (rejected by insurance)

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2nd visit (April 10, 2012)

• Dr. P
• Cc persistent Rt. Nasal obstruction with
  recurrent epistaxis
• Nasopharynggoscopy done

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Nasopharyngoscopy

• Examination
• Mass, dark round, fill nasopharynx, seems to be
  originating from right side
• Dx- bleeding mass
• nasopharynx inverted papilloma/hemangioma.

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• Dr. P. advised CT scan histopathology
• Prescribed Otrivin nasal Spray

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3rd visit- (August 26, 2012)

• Ct- scan done with contrast

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Nursing Responsibilities

• Explain the procedure to the client
• Assess allergy to dye.
• Secure consent for the procedure.
• Insert IV cannula aseptically as the dye will
  inject in through the vein.

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• Inform that the client may feel hot sensation
  when dye is injected.
• Encourage the client to drink plenty of water
  after the procedure.

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CT Image Result (Aug 26, 2012)

• Normal client

• Mr. m

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CT Result
Possible dx Nasopharyngeal carcinoma Granulomatou
s lesions
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Sept. 2, 2012

• Biopsy was done
• Confirmed the dx of nasopharyngeal cancer

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Nursing Responsibilities

• Explain the procedure to the client.
• Informed consent
• Make sure all the equipments needed are
  available.
• Send tissue samples at the laboratory in a
  sterile container with formalin.

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Advised by Dr. P.

• Chemotherapy

• Radiotherapy

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Introduction
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Nasopharyngeal cancer
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Anatomy Physiology
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Etiology
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Nasopharyngeal Cancer

• Types of Tumors
• Benign- non cancerous
• Malignant- cancerous

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Staging of NPC
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2 Ways of Staging Cancer

• TNM System
• Number system

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Tumor Nodes Metastasize
T0- no tumor N0- no lymph nodes M0- not spread in other parts of the body
T1- within the nasopharynx, oropharynx or nasal cavity N1- cancer cells in lymph nodes on one side of the neck, not gt 6cm across M1- cancer has spread to other parts of the body.
T2- spread into the areas next to nasopharynx, not spread into the bone N2- cancer cells in lymph nodes on both sides of the neck, gt 6m across
T3- spread into the sinuses T4- spread in one or more Cranial nerves Hypopharynx Eye or surrrounding tissue Bony spaces N3- N3a- cancer cells in one or more lymph nodes , one node is gt 6cm across N3b- there are cancer cells in the supraclavicular area
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Number Staging of Cancer
No. Stage Description
Stage 0 Stage 1 Stage 2 Carcinoma in situ Not spread Larger cancer, affects more than half the area of nasopharynx
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No. Staging Description
Stage 3 Stage 4 4a 4b 4c Spread Oropharynx Throat Nearby b0nes and air cavities Advanced stage -grown within the skull -nearby tissues and bones -spread in other parts of the body ex. lungs
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Risk Factors

• Diets - in salt cured fish and meat
• Epstein Barr Virus Infection
• Genetic Factors
• Male
• Age 30- 55 yrs old
• Asian

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Signs and Symptoms

• Painless and enlarged lymph nodes in the neck
• Nasal obstructions
• Epistaxis
• Diminished hearing
• Tinnitus
• Recurrent Otitis Media
• Cranial Nerve Dysfunctions
• Sore throat
• Headache

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Diagnostic Test

• Medical History and physical Assessment
• Fiberoptic Endoscopic Examination
• Ct Scan

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• MRI (Magnetic Resonance Imaging)
• Biopsy

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Treatments
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Chemotherapy

• Cisplatin - drug of choice
• Side Effects
• Anorexia
• Constipation
• Bone marrow damage
• Hair loss
• Increase risk of infection
• Mouth sores
• Nausea and vomiting
• Fatigue

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Radiation Therapy

• External Beam Radiation/ Brachytherapy
• Side Effects
• Skin burns
• Confusion
• Difficulty of swallowing
• Fatigue
• Hairloss
• Headaches
• Nausea and vomiting
• Rashes and other skin problems
• Weight loss

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Surgery
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Complications

• Bleeding
• Infection
• Difficulty breathing
• Tumor spread to other organs

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9 Warning Signs of Cancer

• Cancer Precaution

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C changes in bowel bladder habits A a sore
that does not heal U unusual bleeding T
thickening lump in breast or elsewhere I
indigestion or difficulty in swallowing O
obvious changes in moles or warts N nagging
cough and hoarseness U unexplained anemia S
sudden weight loss
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Pathophysiology
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Unknown

• Predisposing Factors
• Asian
• Men 30-50yrs old
• Hereditary

• Precipitating Factors
• Cigarette Smoking
• Alcohol Abuse
• Occupational exposure
• Diet salt preserved foods

Genetic Mutation
Uncontrolled cell division at squamous cells that
line the nasopharynx
Untreated
Pre- malignant cell
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Cell continues to divide out of control and all
daughter cells produced with the same ability
Increased in malignant and appearance
Cancer cells confined in the cells of the throat
(nasopharynx greatly affected)
Signs and symptoms occur
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• Drug Study

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Name Classifications Actions Indications Contraindications Adverse Reaction Nursing Considerations
Generic Name Xylometazoline Brand Name Otrivin Decongestant It works by constricting blood vessels that leads to a decrease in congestions. The formulation acts directly on the blood vessels in the nose and sinuses Nasal congestions due to cold, sinusitis Respiratory allergies High blood pressure Heart disease Irregular heartbeat Thyroid problems Diabetes Pregnant woman Glaucoma Dizziness Sweating Tiredness Slow heart rate Advice the client not to use drug gt 3-5 days, longer use could cause damage to nasal tissue Advice client that this drug should not be use with MOA. strictly follow the instructions ordered by the doctor
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Name Classifications Actions Indications Contraindications Adverse Reactions Nursing Considerations
Generic Name Cisplatin Brand Name Platinol Antineoplastic May cross link strands of cellular DNA and interfere with RNA transcription, causing an imbalance of growth that leads to cell death Head and neck cancer Others Prostate cancer Hypersensitivity do drug Severe renal disease Hearing impairment Renal failure Liver failure Ocular toxicity neuritis Monitor intake and output Advise pt. to watch for signs of infection Tell pt to immediately report ringing in the ears and numbness in hands or feet
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Prioritization of Nursing Problem
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Nursing Diagnosis

• Ineffective Airway Clearance related to nasal
  blockage as manifested by presence of mass in
  nasal cavity as seen through rigid endoscopy.
• Ineffective Breathing Pattern related to nasal
  obstruction as manifested by respiratory
  irregularities and mouth breathing.
• Activity Intolerance related to weakness

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• Therapeutic Regimen management Readiness for
  enhance as manifested by frequent asking
  questions regarding disease treatments.
• Impaired verbal communication related to
  inability of air pass through the nose as
  manifested by mouth breathing and difficulty of
  uttering words
• Knowledge deficit, management of therapy and
  treatment related to misinterpretation of
  information.

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• Risk for Imbalanced Nutrition less than body
  requirements as a result of nausea and vomiting,
  side effects of chemotherapy.
• Risk for Impaired skin integrity related to side
  effects of chemotherapy and radiotherapy.
• Risk for situational Low self esteem.

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Nursing Care Plan
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Cues Nsg Dx Planning Interventions Rationale Evaluation
Subjective I cant breathe through my nose as verbalized by the client. Objective Mouth breathing Clogged nose Resp irregularities RR- 34/min With right nasal bleeding Ineffective Airway Clearance related to nasal blockage as manifested by mass seen through rigid endoscopy At the end of 8 hrs of duty the clients respiratory irregularities will improve. Proper breathing technique demonstrated like breathing through mouth in perfect rhythm Otrivin 0.1, 1 nasal spray given each nostril 3 x a day as prescribed by the physician. To improve respiratory difficulties. Helps to reduce symptoms of nasal congestions, works by narrowing the blood vessels in the lining of the nose. After the 8 hrs of duty client respiratory irregularities improved as manifested by RR- 26/min
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Health teaching done as follows Client need to stop smoking Use mask when expose to dust and chemicals Eat foods rich im CHO, fats. Limit intake of salty, grilled, fried and smoked foods Smoking triggers more complications like difficulty of breathing and possible infections. The client is immunocompromised. To increase clientss stamina since he is still working. Since this foods are contributing factors of having NPC
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Nursing Health Teaching
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• Advised client to use protective equipments like
  mask when exposed to dust and any chemicals.
• Encouraged to strictly follow treatment regimen.

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• Encouraged to eat small frequent feedings to
  reduce nausea, take anti- nausea medications as
  prescribed
• Encouraged to drink at least 1- 2 liters of fluid
  every 24 hrs, unless the client are instructed to
  limit fluid intake.

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• Drinking alcohol beverages should be kept to a
  minimum or avoided completely
• Encouraged to stop smoking completely
• Encouraged to get plenty of rest and maintain
  good nutrition.

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Conclusion
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• Presented a case of 46 yrs old client with
  chief complaint of right nasal obstruction, nose
  bleeding. Nasopharyngoscopy shows presence of
  mass in nasal cavity with CT scan and
  histophatology report pertaining to common
  diagnosis nasopharyngeal carcinoma

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• Treatment for nasopharyngeal carcinoma involves
  combination of radiation and chemotherapy for
  this client.
• Early detection of nasopharyngeal cancer is vital
  for treating the disease to prevent its
  development and metastasis.

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• The stage of cancer, size of tumor, the clients
  age, general health and compliance to treatment
  regimen are factors that can affect prognosis.

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• Cisplatin is the drug of choice in this case.
• Nursing management includes provision of an
  emotional supportive environment, encouragement
  for strict compliance of treatments are important.

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Bibliography

• Gleeson, michael Otorhinolaryngology Head and
  Neck Surgery. (editon 2008)
• Htpp//www.cancer.gov/cancertopics
• Htpp//www.medicenter.com/nasopharyngealcancer/art
  icles
• Modalities of surveilance in treated
  nasophayngeal cancer. Head and Neck Surgery.

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Jeanelyn VirtucioSpeaker

• Presented by EENT department