Case 3
Dx : C53.9 Cervix uteri malignant neoplasm, unspecified Stage

Laboratory test
21 December 2021 Lab : Cr 0.6, LFT normal, Hct 36.2%, WBC 3200, ANC 1500, Plt 257000


Tumor marker : CA 125 = 49.54 (decrease)


BW 56.3, Ht 158, BSA 1.57 Cr 0.6 CrCl 109.66

Chief complain : The patient has appointment for Chemotherapy, Cisplatin 5FU cycle 2

Pathology
Cervical cancer is usually a squamous cell carcinoma caused by human papillomavirus infection; less often, it is an adenocarcinoma. Cervical neoplasia is asymptomatic; the first symptom of early cervical cancer is usually irregular, often postcoital vaginal bleeding. Diagnosis is by a cervical Papanicolaou test and biopsy. Staging is clinical, combined with imaging and pathology results when available. Treatment usually involves surgical resection for early-stage disease or radiation therapy plus chemotherapy for locally advanced disease. If the cancer has widely metastasized, chemotherapy is often used alone.

Other risk factors for cervical cancer include :
⚡ Younger age at first intercourse
⚡ A high lifetime number of sex partners
⚡Cigarette smoking Immunodeficiency
⚡ Hormones following ageing
⚡ women who have taken the contraceptive pill for five years or more are at increased risk of developing cervical cancer


Regardless of sexual history, clinicians should assume that women have been exposed to someone with HPV because it is ubiquitous.

Invasive cervical cancer usually spreads by direct extension into surrounding tissues or via the lymphatics to the pelvic and para-aortic lymph nodes. Hematogenous spread is possible but rare.


If cervical cancer spreads to the pelvic or para-aortic lymph nodes, the prognosis is worse, and the location and size of the radiation therapy field is affected.

Nursing care plan

1. Risk for side effect of Chemotherapy.


Objective data :
Chemotherapy : Cisplatin 5FU cycle 2, WBC 3200 Cells/uL, ANC 1500 Cells/uL, diet as tolerate, BMI 22.55

Analysis of risk for malnutrition


Chemotherapy affect nutrition in different ways. Chemotherapy affects cells all through the body. Chemotherapy uses drugs to stop the growth of cancer cells, either by killing the cells or by stopping them from dividing. Healthy cells that normally grow and divide quickly may also be killed. These include cells in the mouth and digestive tract.


Chemotherapy cause different nutrition problems. Side effects from chemotherapy may cause problems with eating and digestion. When more than one chemotherapy drug is given, each drug may cause different side effects or when drugs cause the same side effect, the side effect may be more severe. The following side effects are common:



⭐ A hospital stay being unwell in hospital can affect to their appetite and their ability to take in food.


⭐ Anxiety or depression being unwell and living with a cancer diagnosis is understandably stressful and can lead to anxiety or depression, which can impact on nutritional intake.

Nursing goal

  1. To prevent side and symptoms of chemotherapy.
  2. To promote appropriate nutrition for the patient.
  3. To prevent and reduce risk of infection.

Evaluation criteria

  1. Stable weight and BMI not less than 18.5
  2. The patient can eat more by more than half of plate.
  3. No have signs and symptoms of malnutrition such as poor appetite, unplanned weight loss, weakness, fatigue, nausea and vomiting.
  4. The patient did not have signs of infection such as fever, chill and sweats.
  5. Vital sign are normal.
  6. Laboratory results are normal.

Nursing intervention

Risk for malnutrition

  1. Monitor daily food intake; have patient keep food diary as indicated. For identifies nutritional strengths and deficiencies.
  1. Assess skin and mucous membranes for pallor, delayed wound healing, enlarged parotid glands.
  1. Encourage patient to eat high-calorie, nutrient-rich diet, with adequate fluid intake. Encourage frequent or smaller meals spaced throughout the day.
  1. Create pleasant dining atmosphere; encourage patient to share meals with family and friends. Makes mealtime more enjoyable, which may enhance intake.
  1. Adjust diet before and immediately after treatment (clear, cool liquids, light or bland foods, candied ginger, dry crackers, toast, carbonated drinks). Give liquids 1 hr before or 1 hr after meals.
  1. Control environmental factors (strong or noxious odors or noise). Avoid overly sweet, fatty, or spicy foods. Because It can trigger nausea and vomiting response.
  1. Administer Plasil 10 mg PRN every 8 hr. For prevent nausea and vomiting.

2. P-D-METHOD

  1. Record intake and output for assess amount of fluid that the patient intake.

Analysis
The most effective way to increase the probability that the patient will implement a self care regimen after discharge is to identify the patient’s priorities following P-D-METHOD. This patient is hospitalized due to continue received Chemotherapy. Therefore, side effects of treatment will effect to the patient can cause uncomfortable or lack of self care. The nurse will using P-D-METHOD to assess and educate the patient will help the patient to understand in appropriate self care and can relief pain by herself.

Nursing goal

  1. The patient has knowledge and able to take care of herself after received chemotherapy.

Evaluation criteria

  1. The patient understand and can explain the appropriate self care.
  2. Patient can answer the question 4 to 5 items.

Nursing intervention

  1. Assess and evaluate knowledge of the patient in self care at home after received chemotherapy.
  1. Give information about taking care of yourself. When receiving chemotherapy by using P-D- METHOD
  1. Give a chance to the patient to ask a question.
  1. Assess understanding information by ask a question that patient can answer correctly 4 out of 5 questions.

P - D - METHOD

  • P- Phychological support Psychological care, managing stress or anxiety of patients and their relatives, including Empowerment, proper health care.
  • D - Diagnosis is to educate about disease, causes, symptoms.
  • M - Medicine is a recommendation to use the medicine that the patient receives.
  • E - Environment Management guide the home environment is suitable for patient health.
  • H - Heath the patient and family understand her health conditions, such as limitations, effects of illness, and be able to adjust their daily lifestyle to suit their health limitations, contributing to rehabilitation and prevention of complications.
  • O - Out patient The importance of scheduled follow-up visits.
  • D - Diet advises the patient to understand and be able to choose food that is appropriate for health conditions and limitations appropriate to economic conditions.

Home medicine

  1. Ferrous fumarate 200 mg 1 x 3 pc (90 tabs) Ferrous fumarate is an iron drug. Take for iron supplementation in people with iron deficiency.



    Side effects : feeling or being sick (nausea or vomiting), stomach discomfort or heartburn, loss of appetite, Constipation, diarrhea, dark or black stools.

  1. Folic 1 x 1 pc (30 tabs) Folic acid signs of an allergic reaction to folic acid : hives, rash, itching, skin redness; wheezing, difficult breathing; swelling of face, lips, tongue, or throat.

Common side effects may include: nausea, loss of appetite, bloating, gas, stomach pain, bitter or unpleasant taste in mouth

  1. Metoclopramide 10 mg 1 x 3 ac (20 tabs) is also used to treat gastroparesis (slow stomach emptying)

side effects of the drug are relatively minor and include restlessness, drowsiness, fatigue and a general lack of energy.

4. Ondansetron 8 mg 1 x 2 ac (20 tabs) is used to prevent nausea and vomiting that may be caused by surgery, cancer chemotherapy, or radiation treatment.


side effect headache, constipation, weakness, tiredness, chills, drowsiness

5. Lorazepam 0.5 x hs prn for insomnia (10 tabs) Lorazepam used to treat anxiety and sleeping problems that are related to anxiety.


Common side effects

  • feeling sleepy or very tired in the daytime
  • muscle weakness
  • problems with coordination or controlling movements

6. Tramol 50 mg. 1 cap oral prn pain every 8 hr (30 tabs) Tramadol is used to treat moderate to severe pain.


Side effects include : dizziness, headache, drowsiness, nausea and vomiting, constipation, lack of energy, sweating, dry mouth, itching.

Present illness :

  • 2 years ago (September), the patient has excessive vagina bleeding and burning urine. Then, she went to Ra-yong Hospital for examination the doctor diagnosed Moderately differentiate Adenocarcinoma, size 2.4x1.8x1.4 cm. At lymphovascular space involvement (LVSI), not free parametrium both side.


  • 21 September 2020, The patient received operation status Radical Hysterectomy and Systematic Pelvic Lymphadenectomy (RHPL) with Bilateral Salpingo-Oophorectomy (BSO) at Phyathai-Sriracha Hospital.


  • 5 November 2020, post operation Concurrent chemo-radiation therapy (CCRT) at Phyathai-Sriracha Hospital. The patient always saw the doctor for follow up her treatment. And then, the patient has recurrent CA Cervix (paraaortic and aortocaval LN) by unknown clear data of recurrent diagnosis.


  • 21 December 2021, the patient has appointment for received treatment by chemotherapy Cisplatin 5FU Cycle 2

Physical examination


  • The patient is middle age adulthood. Good consciousness and good orientation in place, person, time. Skin, hair, nails are clean. She can do everything by herself assess from Eastern Cooperative Oncology Group (ECOG) Performance Status : ECOG 0 is means Asymptomatic, normal activity.


  • Supraclavicular lymph nodes and inguinal lymph nodes are negative.


  • HEENT - no pale, no jaundice


  • Heart - normal S1S2


  • Lung - clear no crepitation


  • Abdomen - soft, no distension


  • Extremities - normal movement, no edema

Past history illness :
The patient denies family history of cancer.

  1. Assess the patient by use tools Patient Health Questionnaire-2 (PHQ-2)

The PHQ-2 inquires about the frequency of depressed mood and anhedonia over the past two weeks. The PHQ-2 includes the first two items of the PHQ-9.

The purpose of the PHQ-2 is to screen for depression in a “first-step” approach.

Patients who screen positive should be further evaluated with the PHQ-9 to determine whether they meet criteria for a depressive disorder.

Patient Health Questionnaire: PHQ-9 The PHQ-9 is a multipurpose instrument for screening, diagnosing, monitoring and measuring the severity of depression.

1.) Explain inthe overview of cervix cancer.

Cervical cancer is a cancer that's found anywhere in the cervix.

The cervix is the opening between the vagina and the womb (uterus).

It's part of the reproductive system and is sometimes called the neck of the womb.

Nearly all cervical cancers are caused by an infection from certain types of human papillomavirus (HPV).

It can often be prevented by attending cervical screening, which aims to find and treat changes to cells before they turn into cancer.

Cervical cancer usually grows very slowly. How serious it is depends on how big it is, if it has spread and your general health.

2.) Main symptoms of cervical cancer. Symptoms of cervical cancer include:

vaginal bleeding that's unusual for you – including bleeding during or after sex, between your periods or after the menopause, or having heavier periods than usual

changes to your vaginal discharge

pain during sex

pain in your lower back, between your hip bones (pelvis), or in your lower tummy

3.) Cause of cervical cancer. Nearly all cervical cancers are caused by an infection with certain high-risk types of human papillomavirus (HPV). You can get HPV from:


  • any skin-to-skin contact of the genital area
  • vaginal, anal or oral sex
  • sharing sex toys
  • you're under 45 – cervical cancer is more common in younger people
  • you have a weakened immune system, like if you have HIV or AIDS
  • you have given birth to multiple children or had children at an early age (under 17 years old)
  • your mother took the hormonal medicine diethylstilbestrol (DES) while pregnant with you – your GP can discuss these risks with you
  • you've had vaginal, vulval, kidney or bladder cancer in the past

Who is more likely to get cervical cancer
Anyone with a cervix can get cervical cancer. This includes trans and non-binary people with a cervix. You might also be more likely to get cervical cancer if:

  • T - Treatment Treatment for cervical cancer. Cervical cancer is often treatable. The treatment you have will depend on:
  • the size and type of cervical cancer you have
  • where the cancer is
  • if it has spread
  • your general health

It will usually include surgery, chemotherapy or radiotherapy. It may also include treatment with targeted medicines to treat the cancer.

1.) Surgery : Surgery is the often the main treatment for cervical cancer, especially if the cancer is found early. There are several surgeries used to treat cervical cancer. Different surgeries involve removing:

2.) Chemotherapy : Chemotherapy uses medicines to kill cancer cells. You may have chemotherapy for cervical cancer:

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  • part of the cervix – only possible if the cancer is very small
  • the cervix and upper part of the vagina – the womb is not removed, so it's possible to get pregnant in the future
  • the cervix and womb (hysterectomy) – can include removing the ovaries and fallopian tubes
  • the cervix, womb, ovaries and fallopian tubes, and all or parts of the bladder, bowel, vagina or rectum – this is only offered if the cancer has come back and other treatment is not possible

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  • with radiotherapy (chemoradiotherapy) as the main treatment for your cervical cancer
  • before surgery to help make the cancer smaller
  • after surgery (usually with radiotherapy) to help stop the cancer coming back
  • if the cancer is advanced, has come back or if it’s spread to other parts of your body

3.) Radiotherapy : Radiotherapy uses high-energy rays of radiation to kill cancer cells. You may have radiotherapy for cervical cancer:

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  • as the main treatment if the cancer is large or has spread
  • after surgery, usually with chemotherapy (chemoradiotherapy), to help stop the cancer coming back
  • to help improve symptoms, like bleeding
  • Radiotherapy for cervical cancer can be given from outside or inside the body (brachytherapy).

Avoid that are at risk of infection, such as avoiding people who are unwell, such as :

  • having a cold
  • coughing
  • not sharing personal items with others (such as towels)
  • avoid being in a crowded place (For example, a market that is at risk of getting germs. If it is necessary to be in a place where there is a risk of infection, you should wear a mask.)

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Like most cancers, cervical cancer can spread to other parts of the body and cause serious complications. However, when cervical cancer is caught and treated early, the expected outcome is usually very good.

Treatments for cervical cancer can affect your ability to fall pregnant and/or carry a pregnancy to term. Smaller surgical procedures performed on the cervix may increase the chance of miscarriage in future pregnancies.

The larger surgeries, which remove the uterus (hysterectomy), fallopian tubes (bilateral salpingectomy) or ovaries (bilateral oophorectomy), may mean you will not be able to have children.

Cancer treatments, including surgery, chemotherapy, and radiotherapy, may all cause a range of side effects. Your medical team is very experienced at helping people manage these side effects and can give you advice and support to manage them.

Side effect of chemotherapy are easy to infection and risk for malnutrition.

  • easy to infection: important of self hygiene care because after the patient received chemotherapy that make the body low immune due to bone marrow suppressive. So, hygiene should be the most attention.
  • risk for malnutrition: side effect of chemotherapy are poor appetite, dry tongue, sore throat, and other. So the patient should try to eat because foods help the body recovery.
  • Next appointment is 11 January 2020
  • Laboratory test : CBC, BUN, Cr, LFT, CA 125

Avoiding specific foods and drinks such as cooked meats, herbal tea, or alcohol. You may be told to not eat cooked meat for 24 hours before your test. Studies have shown that cooked meat can temporarily raise creatinine levels.

Making sure not to overeat the day before a test

Not smoking

Avoiding specific behaviors such as strenuous exercise or sexual activity

Avoiding certain medicines and/or supplements. Be sure to talk to your provider about what you are currently taking, including over-the-counter medicines, vitamins, and supplements.

that aerobic exercise (such as walking, jogging, or cycling) and strength training (such as lifting weights or using resistance bands) can benefit cancer patients.

Questions

  1. What is cervix cancer, symptoms and how to treat with cancer?
  1. What is the side effect of chemotherapy?
  1. How to prevent infection after received chemotherapy?
  1. How to reduce nausea and vomiting?
  1. How to take medications when the patient back to home?

Encourage patient to eat high-calorie, nutrient-rich diet, with adequate fluid intake. Encourage frequent or smaller meals spaced throughout the day.

Create pleasant dining atmosphere; encourage patient to share meals with family and friends. Makes mealtime more enjoyable, which may enhance intake.

Adjust diet before and immediately after treatment (clear, cool liquids, light or bland foods, candied ginger, dry crackers, toast, carbonated drinks). Give liquids 1 hr before or 1 hr after meals.

Control environmental factors (strong or noxious odors or noise). Avoid overly sweet, fatty, or spicy foods. Because It can trigger nausea and vomiting response.

Screening is used to look for health problems that affect the risk of poor nutrition. This can help find out if the patient is likely to become malnourished, and if nutrition therapy is needed.

Weight changes over the past year.

Changes in the amount and type of food eaten.

Problems that have affected eating, such as loss of appetite, nausea, vomiting, diarrhea, constipation, mouth sores, dry mouth, changes in taste and smell, or pain.

Ability to walk and do other activities of daily living (dressing, getting into or out of a bed or chair, taking a bath or shower, and using the toilet).

A physical exam is done to check the body for general health and signs of disease. The patient is checked for signs of loss of weight, fat, and muscle, and for fluid buildup in the body.

Analysis of risk for infection
White blood cells are responsible for fighting various pathogens that enter the body. Normally, white blood cells are lowered from 2-3 days after receiving chemotherapy and will be lowest in 7-14 days after the body will produce more white blood cells until returns to normal 21-28 days after chemotherapy. Low white blood cell counts can lead to infection more easily and more severely than the general population. Leukopenia is the most common condition that can be divided into severity was defined as an absolute neutrophil count (ANC) in 3 levels: mild white blood cell (1000-1500 cells/uL), moderately low white blood cell (500 1000 cells/uL). and severely low white blood cell (<500 cells/uL)

Risk for infection

  1. Assess vital signs because high temperature, short of breath, High heart rate can show early signs of infection.
  1. Evaluate knowledge of the patient in risk and prevent of infection.
  1. Provide information the risk of infection. Due to the patient received chemotherapy that effect to bone marrow suppression. During chemotherapy, a decrease in white blood cells, red blood cells, and platelets is can easy to infection.
  1. Practices to avoid infection.
  1. Promote personal hygiene and limits potential sources of infection and secondary overgrowth.
  1. Promote adequate rest and exercise periods.
  1. Avoid or limit invasive procedures. Adhere to aseptic techniques. For reduces risk of contamination, limits portal of entry for infectious agents.
  1. Monitor laboratory test. Because bone marrow activity may be inhibited by effects of chemotherapy, Monitoring is important for preventing further complications (infection, anemia, or hemorrhage).

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  1. Avoid that are at risk of infection, such as avoiding people who are unwell, such as having a cold, coughing, not sharing personal items with others (such as towels), avoid being in a crowded place (For example, a market that is at risk of getting germs. If it is necessary to be in a place where there is a risk of infection, you should wear a mask.)
  1. Eat well-cooked food, avoid fermented food or don't have sealed containers.
  1. Avoid approaching animals such as dogs, cats because these animals tend to have germs attached to them.
  1. Maintain cleanliness of the body regularly, wash hands frequently and be careful not to cause wounds because germs will easily enter the wound.
  1. Suspicious symptoms that there is an infection, including fever, cough with mucus, sore throat, red, swollen skin with pus or inflamed lesions, loose stools or burning urine should see a doctor immediately.
  1. Promote personal hygiene and limits potential sources of infection and secondary overgrowth.
  • Loss of appetite.
  • Nausea.
  • Vomiting.
  • Dry mouth.
  • Sores in the mouth or throat.
  • Changes in the way food tastes.
  • Trouble swallowing.
  • Feeling full after eating a small amount of food.
  • Constipation.
  • Diarrhea.

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