NURSING PROCESS

STUDENTS PROFILE:

Name- Namitha

Class- Msc. Nursing 1st year

Clinical area- Oncology

Specific unit- Oncosurgery

Duration of posting- 2 days

Duration of care- 2 days

INTRODUCTION:

My patient Siraja Begum was admitted to oncology ward on 18th December, 2016 with the
complaints of intermittend fever and abdominal pain that are painful and progressive in nature
from past 2 months. She is also having weight loss.

CLIENT PROFILE:

Name- Siraja Begum

Age/sex- 56years/Female

Ward- Oncology

Bed no- 24

Date of admission-18/12/2016

Education- Uneducated

Religion- Muslim

Occupation- Housewife

Marital status- married

DIAGNOSIS- Carcinoma ovary

HISTORY TAKING
GENERAL HISTORY

Siraja begum is a healthy lady of 56 yrs.She is living a normal life. Married at the age of 15 yrs
and have 2 children.She didnt had any significant disease in her lifetime.Now she is diagnosed
as a case of cancer ovary.

MARITAL HISTORY

Married on 1975 (at 15 yrs of age) and have 2 male children.

FAMILY HISTORY:

S.NO. Name of the Age/Sex Relationship Education Occupation Health

family condition
member
1. Siraja begum 56/F Head of the Nil Housewife Patient
family
2. Hazheer 34/M Son 12th Govt servant Healthy

3. Fareeda 29/F Daughter in 5th Housewife Healthy

law
4. Abdul 10/M Grandson 5th Student Healthy

5. Fazil 8/M Grandson 3rd Student Healthy

6. Aisha 4/F Granddaughter 1st Student Healthy

7. Ruksana 2mon/F Granddaughter Healthy

8 Sameer 32/M Son 12th Prvt job Healthy

9 Hazena 27/M Daughter in 8th Housewife Healthy

law
10 Zoya 8/F Granddaughter 4th Student Healthy

11. Rahmat 5/M Grandson 2nd Student Healthy

 FAMILY TREE:

SOCIOECONOMIC HISTORY:

My patient belongs to a middle class family. She lives in her own pucca house with her joint
family. The house is equipped with all the necessary amenities like safe drinking water, proper
electricity, LPG connection, and good sanitation facilities.

MENSTRUAL HISTORY

Have a normal menstrual cycle.Menarche at 13 yrs of age.Normal flow of 4-5 days with slight
clotes.Menopause at 52 yrs.

OBSTETRICAL HISTORY

Sl.no Year Full Nature Pre- Abortion Alive Still Sex Birth Growth and
term of mature born weight development
delivery Spontaneous/induced

1 1976 FT FTNVD - - - M 2.6 Adequate

2 1979 FT FTNVD - - M 3 Adequate

HISTORY OF PRESENT ILLNESS-

My patient Siraja begum was apparently wellbefore 4 months when she started having
intermittent fever lasting for 4 or 5 days. She has taken treatment from the local physician but his
complaint doesnt subside and was mistaken as a case of typhoid fever. After a month she started
noticing increase in her abdominal size.She consulted the same physician and he advised an
ultrasound. Symptoms increased progressively. Report suggested an subnormal growth in ovary
.She was reffered to BMHRC for further treatments. Here after investigations she is diagnosed
as carcinoma ovary. She is admitted in oncology ward for surgery.Routine investigations are
being done.She was suffering from fever on 18th night.

GORDONS FUNCTIONAL HEALTH PATTERN ASSESSMENT:

1. Health perception-health management pattern-

My patient Siraja is worried about the diagnosis. she believes it at wish of allah to test her
strength. But, at the same time she is very hopeful for the treatment and bears a positive
attitude to deal with the disease. she takes good care of himself and follows the treatment
process.

2. Nutrition-metabolic health pattern-

Diet: My patient is non-vegetarian and takes three meals per day normally.

Appetite: My patient has decreased appetite .

Hydration: Good.

3. Elimination pattern-

My patient is having normal bowel and bladder movement. she is voiding self. No fresh
complaints were reported by my patient regarding change in his bowel and bladder
movement due to his newly diagnosed disease.

4. Activity exercise pattern-

My patient is experiencing generalized fatigue due to which his activity reduced as compared
to pre-morbid state. But she is doing his activities of daily living by himself only. The patient
is very cheerful and enjoys company of other patients around her.

5. Sleep rest pattern-

My patient is having normal sleeping pattern. Even having diseased he has not experienced
any significant changes in his sleeping pattern. She reported no abnormalities regarding
sleep. She sleeps 8 to 10 hours per day like his pre morbid state.

6. Cognitive perceptual pattern-

My patient is having normal cognitive and perceptional status. She is accurately able to
perceive the visionary, olfactory or gustatory stimulus she is getting. Her cognition is alright.
No abnormal responses are reported by her family members.
 7. Self perception pattern-

My patient is showing healthy self perception behaviour. She is very optimistic regarding the
disease and very hopeful for her treatment. She is satisfied with the treatment services
provided by the hospital. According to her, diseased condition is the wish of god and he will
provide her the strength for everything

8. Role relationship pattern-

My patient is having healthy relationship with her family members and neighbors. She is
enjoying good family support during her illness. Her family reports no abnormal behaviour
shown by the patient during illness or even during pre-morbid state.

9. Sexuality reproductive pattern-

G3 P3 A0 L3. No history of any abortions or complications.Had 2 FTNVD.

10. Coping stress tolerance pattern-

She is very optimistic regarding the disease and very hopeful for her treatment. She is
satisfied with the treatment services provided by the hospital. She is coping his stress very
well. She is friendly in nature; enjoys company of other patients.

11. Value belief pattern-

My patient is very religious. According to her, diseased condition is the wish of god and he
will provide her the strength for everything. She prays to him god for his wellness

PHYSICAL EXAMINATION:

1. GENERAL EXAMINATION-

General appearance- my patient appears normal.

Orientation- she is oriented to time place and person.

Speech- she exhibited clear speech

Body movements- restricted body movements due to lethargy

Nourishment- Patient was experiencing decreased in appetite due to illness

Height- 155cm

Weight- 62kg

2. VITAL SIGNS-

Temperature- 98.2 F
Pulse- 80 beats/min

Respiration- 20 breaths/min

Blood pressure- 110/74mmhg

3. INTEGUMENTARY SYSTEM-

Colour- wheatish

Texture- normal

Turger- healthy skin turgor present

Lesions and other signs- no other abnormal signs or lesions noticed

4. NAILS-

Colour- pale

Capillary refill- normal capillary refill present i.e. less than 3 seconds

Other symptoms- none

5. HEAD AND NECK-

Shape round

Dandruff- absent

Hair- healthy

Range of motion- adequate range of motion present

Lymph nodes- lymph nodes were within normal limits no swelling detected

Other symptoms- none

6. EYES-

Symmetry- symmetrical

Conjunctiva- healthy

Cornea- healthy

Pupils- healthy

Vision- healthy

Other symptoms- healthy

7. EARS-

Position- normally position

External ear- healthy, no wax

Hearing- present

Other symptoms- none

8. MOUTH-

Symmetry- symmetrical

Lips- pink, dry

Teeth- yellowish with dark brown spots, cavity present.

Tongue- symmetrical, muscular, functioning normally

Appetite- decreased appetite due oral lesions

Other symptoms- reddish lesions are present on oral mucosa.

9. ABDOMEN-

Inspection- Distended

Palpation- no organomegaly present, tenderness.

Percussion- . - Fluid accumulation suggesting ascitis

Auscultation- normal healthy bowel sounds were detected

Other symptoms- no other abnormality detected or reported

10. EXTREMITIES-

UPPER EXTREMITIES

Symmetry- symmetrical

Range of motion- normal range of motion

Edema- no edema present

Pain- no pain on upper extremities is reported

Other symptoms- no other abnormality detected or reported

LOWER EXTREMITIES

Symmetry- symmetrical

Range of motion- normal range of motion

Edema- no edema present

Pain- no pain on upper extremities is reported

Other symptoms- no other abnormality detected or reported

11. RECTUM AND GENITALS-

Skin colour- normal

Bowel habits- normal, voiding self

Bladder movement-normal, voiding self.

Other symptoms- none

FOCAL ASSESSMENT

ABDOMEN-

Inspection- Distended. Abdominal girth .110 cm on 18th morning

Palpation- no organomegaly present, tenderness.

Percussion- Fluid accumulation suggesting ascitis

Auscultation- normal healthy bowel sounds were detected

Other symptoms- no other abnormality detected or reported

DIAGNOSTIC TEST:
 Date Name of investigations Patient value Normal value Remarks

17/12/16 Blood investigations:

Hemoglobin 10.8 gm/dl 12-14 gm/dl Low
TLC 8000 8000-11000 Normal
Platelets 2.48 lakhs/cu.cm 1.5-2.5 lakhs/cu.cm Normal
B. Urea 10 mg% 10-50 mg% Normal
B. Creatinine 0.45mg% 0.6-1.4 mg% Low
Bilirubin 0.69 mg% Upto 1.1 mg% Normal
SGOT 24 IU Upto 50 IU Normal
SGPT 27 IU Upto 50IU Normal
Alkaline phosphate 162 mg% Upto 240 mg% Normal
S. Sodium 131 m.mol/L 130-150 m.mol/L Normal
S. Potassium 4.05 m.mol/L 3.0-5.0 m.mol/L Normal

10/11/16 Biopsy Well differentiated Normal cells Abnormal

stromal cell
carcinoma
detected on right
ovary.

10/12/16 Doppler study(HEART) Diastolic Normal function Abnormal

dysfunction
(Grade 1)

9/10/16 MRI peivis Soft small Normal cells Abnormal

enhancing tissue
lesion of size
1.6*1.2 cm in right
ovary

10/12/16 USG-abdomen +pelvis Rt ovarian mass Normal Abnormal

with slight
metastasis to
fallopian tube
 MEDICATIONS

SL Name Dose Route Frequency Action Side-effects Nsg res

no
1 Rantac 40 mg Po HS H2 antagonist Abdominal Administer
cramps empty stomach

2. B.Complex B12 - Po OD Vitamin B Allergic Watch for any

500mg supplement reactions allergic
reactions

CRITICAL PATHWAY

Sl .no Name of 18/12/2016 19/12/2016

investigation
1 Hb 12.6 12.3

2 TLC 8800 8902

3 DLC N67 L27 E3 M4 N68 L26 E4 M2

4 ESR 19 18

5 Platelets 4 4.02

6 Total protein 6.83 6.8

7 Albumin 3.6 3.2

8 S.Na 142 147

9 S.K 4.27 4.5

10 PT 14.4 14.1

11 INR 1.05 1.05

12 ECG Sinus tachy

13 SGOT 94 92

14 SGPT 67 63
DISEASE PROCESS OF CARCINOMA OVARY
INTRODUCTION

Ovarian cancer is a cancer that forms in an ovary. It results in abnormal cells that have the
ability to invade or spread to other parts of the body. When this process begins, there may be no
or only vague symptoms. Symptoms become more noticeable as the cancer progresses. These
symptoms may include bloating, pelvic pain, abdominal swelling, and loss of appetite, among
others. Common areas to which the cancer may spread include the lining of the abdomen, lining
of the bowel and bladder, lymph nodes, lungs, and liver.

INCIDENCE

Globally, as of 2010, about 160,000 people died from ovarian cancer, up from 113,000 in 1990.
As of 2014, more than 220,000 diagnoses of epithelial ovarian cancer were made yearly. In
2010, an estimated 21,880 new cases were diagnosed and 13,850 women died of ovarian cancer.
Around 1800 of the new diagnoses were sex-cord or stromal tumors.One women in 70 will
develop cancer ovary in her lifetime.Incidence increases after 40 yrs of age and peaks in early
80s.Median age is 63.

ANATOMY AND PHYSIOLOGY

The ovaries are the organs in a womans reproductive system that produce eggs (ova.) They are
almond-shaped and about 3.5 cm (1.5 inches) long. The ovaries are deep in a womans pelvis, on
both sides of the uterus (womb), close to the ends of the Fallopian tubes.

Structure
The ovaries are made up of 3 different types of cells:
 Epithelial cells make up the outer layer covering the ovary (epithelium).
Germ cells are inside the ovary. They develop into eggs.
Stromal cells form the supportive or connective tissues of the ovary (stroma).

Each ovary is surrounded by a thin layer of tissue called the capsule..

Function
The ovaries have 2 main functions. They produce mature eggs. They also make the female sex
hormones, which control reproduction and sexual development.

Estrogen is responsible for the development of secondary sex characteristics, such as the growth
of breasts.

Progesterone prepares the body for conception by causing the buildup of the uterine lining
(endometrium) and other changes.

The ovaries are the main source of estrogen in sexually mature women.

Each month during ovulation, an ovary releases a mature egg. The egg travels down the
Fallopian tube to the uterus. If it is fertilized by a sperm, the egg implants into the lining of the
uterus and begins to develop into a fetus. If the egg is not fertilized, it is shed from the body
along with the lining of the uterus during menstruation.During menopause, the ovaries stop
releasing eggs and producing sex hormones
ETIOLOGICAL FACTORS

IN GENERAL IN PATIENT

Mutations of BRCA 1 & BRCA 2 Older age

Women with breast cancer Obesity
Family history
Older age
Low parity
Endometriosis
PCOD
HRT

PATHOPHYSIOLOGY

Ovarian cancer forms when errors in normal ovarian cell growth occur. Usually, when cells grow
old or get damaged, they die, and new cells take their place. Cancer starts when new cells form
unneeded, and old or damaged cells do not die as they should. The buildup of extra cells often
forms a mass of tissue called a growth or tumor. These abnormal cancer cells have many genetic
abnormalities that cause them to grow excessively. When an ovary releases an egg, the egg
follicle bursts open and becomes the corpus luteum. This structure needs to be repaired by
dividing cells in the ovary. Continuous ovulation for a long time means more repair of the ovary
by dividing cells, which can acquire mutations in each division.

Overall, the most common gene mutations in ovarian cancer occur in NF1, BRCA1, BRCA2, and
CDK12. Type I ovarian cancers, which tend to be less aggressive, tend to have microsatellite
instability in several genes, including both oncogenes (most notably BRAF and KRAS) and tumor
suppressors (most notably PTEN). The most common mutations in Type I cancers are KRAS,
BRAF, ERBB2, PTEN, PIK3CA, and ARID1A. Type II cancers, the more aggressive type, have
different genes mutated, including p53, BRCA1, and BRCA2. Low-grade cancers tend to have
mutations in KRAS, whereas cancers of any grade that develop from low malignant potential
tumors tend to have mutations in p53. Type I cancers tend to develop from precursor lesions,
whereas Type II cancers can develop from a serous tubal intraepithelial carcinoma. Serous
cancers that have BRCA mutations also inevitably have p53 mutations, indicating that the
removal of both functional genes is important for cancer to develop.

CLINICAL FEATURES

IN GENERAL IN PATIENT

bloating Pain in pelvic area

abdominal pelvic pain Increased abdominal girth
pain in the side Increased waist size
abdominal or pelvic pain or discomfort Leg pain
back pain Backpain
irregular menstruation or
postmenopausal vaginal bleeding pain
or bleeding after or
during sexual intercourse
difficulty eating
loss of appetite
fatigue
diarrhea
indigestion
heartburn
constipation
nausea
early satiety and
possibly urinary symptoms

STAGES

TNM STAGES

Stage Description
T Primary tumor
Tx Cannot be assessed
T0 No evidence
T1 Tumor limited to ovary/ovaries
 One ovary with intact capsule, no surface tumor, and negative ascites/peritoneal
T1a
washings
Both ovaries with intact capsules, no surface tumor, and negative
T1b
ascites/peritoneal washings
One or both ovaries with ruptured capsule or capsules, surface tumor, positive
T1c
ascites/peritoneal washings
T2 Tumor is in ovaries and pelvis (extension or implantation)
T2a Expansion to uterus or Fallopian tubes, negative ascites/peritoneal washings
T2b Expansion in other pelvic tissues, negative ascites/peritoneal washings
T2c Expansion to any pelvic tissue, positive ascites/peritoneal washings
Tumor is in ovaries and has metastasized outside the pelvis to the peritoneum
T3
(including the liver capsule)
T3a Microscopic metastasis
T3b Macroscopic metastasis less than 2 cm diameter
T3c Macroscopic metastasis greater than 2 cm diameter
N Regional lymph node metastasis
Nx Cannot be assessed
N0 No metastasis
N1 Metastasis present
M Distant metastasis
M0 No metastasis
Metastasis present (excluding liver capsule, including liver parenchyma and
M1
cytologically confirmed pleural effusion)

ASSESSMENT AND DIAGNOSTIC FINDINGS

Diagnosis of ovarian cancer starts with a physical examination (including a pelvic examination), a blood
test (for CA-125 and sometimes other markers), and transvaginal ultrasound. Sometimes a rectovaginal
examination is used to help plan a surgery. The diagnosis must be confirmed with surgery to inspect the
abdominal cavity, take biopsies (tissue samples for microscopic analysis), and look for cancer cells in the
abdominal fluid. This helps to determine if an ovarian mass is benign or malignant.

Diagnosis includes

Blood test
Ultrasound
Laproscopy
Colonoscopy
Abdominal fliud aspiration
 Ct scan
MRI

MEDICAL AND SURGICAL MANAGEMENT

Chemotherapy

Chemotherapy has been a general standard of care for ovarian cancer for decades, although with
variable protocols. Chemotherapy is used after surgery to treat any residual disease, if
appropriate. In some cases, there may be reason to perform chemotherapy first, followed by
surgery. This is called "neoadjuvant chemotherapy", and is common when a tumor cannot be
completely removed or optimally debulked via surgery. Though it has not been shown to
increase survival, it can reduce the risk of complications after surgery. If a unilateral salpingo-
oophorectomy or other surgery is performed, additional chemotherapy, called "adjuvant
chemotherapy", can be given. Adjuvant chemotherapy is used in stage 1 cancer typically if the
tumor is of a high histologic grade (grade 3) or the highest substage (stage 1c), provided the
cancer has been optimally staged during surgery. Bevacizumab may be used as an adjuvant
chemotherapy if the tumor is not completely removed during surgery or if the cancer is stage IV;
it can extend progression-free survival but has not been shown to extend overall survival.
Chemotherapy is curative in approximately 20% of advanced ovarian cancers; it is more often
curative with malignant germ cell tumors than epithelial tumors.

Surgery

Surgery is the preferred treatment and is frequently necessary to obtain a tissue specimen for
differential diagnosis via its histology. The type of surgery depends upon how widespread the
cancer is when diagnosed (the cancer stage), as well as the presumed type and grade of cancer.
The surgeon, who is usually a specialized gynecologic oncology surgeon, may remove one
(unilateral oophorectomy) or both ovaries (bilateral oophorectomy), the Fallopian tubes
(salpingectomy), the uterus (hysterectomy), and the omentum (omentectomy). Typically, all of
these are removed. For low-grade, unilateral stage-IA cancers, only the involved ovary (which
must be unruptured) and Fallopian tube will be removed. This can be done especially in young
people who wish to preserve their fertility. However, a risk of microscopic metastases exists and
staging must be completed. If any metastases are found, a second surgery to remove the
remaining ovary and uterus is needed. Tranexamic acid can be administered prior to surgery to
reduce the need for blood transfusions due to blood loss during the surger

Radiation therapy

Radiation therapy does not improve survival in people with well-differentiated tumors. In stage
1c and 2 cancers, radiation therapy is used after surgery if there is the possibility of residual
disease in the pelvis but the abdomen is cancer-free. Radiotherapy can also be used in palliative
care of advanced cancers. A typical course of radiotherapy for ovarian cancer is 5 days a week
for 34 weeks. Common side effects of radiotherapy include diarrhea, constipation, and frequent
urination.
Hormonal therapy

Despite the fact that 60% of ovarian tumors have estrogen receptors, ovarian cancer is only
rarely responsive to hormonal treatments. Estrogen alone does not have an effect on the cancer,
and tamoxifen and letrozole are rarely effective.

Immunotherapy

Immunotherapy is a topic of current research in ovarian cancer. In some cases, the antibody drug
bevacizumab, though still a topic of active research, is used to treat advanced cancer along with
chemotherapy. It has been approved for this use in the European Union.

MANAGEMENT IN CLIENT

Stage 2 cancer in right ovary with slight metastasis to fallopian tube.so was posted for bilateral
salphingo oopherectomy and total hysterectomy.

Bilateral salphingo oopherectomy and total hysterectomy.

A bilateral salpingo-oophorectomy is a surgery in which both a woman's ovaries are removed,
along with the fallopian tubes. This surgery is used primarily to treat gynecological cancers such
as ovarian, fallopian, and uterine cancer, although it is used in the treatment of some other
gynecological conditions as well. One of the major consequences of this surgery is that the
woman becomes infertile, and she also stops producing a variety of hormones, which triggers the
onset of menopause.

Depending on the surgeon, a bilateral salpingo-oophorectomy can be performed laproscopically,

or as an open surgery. In both cases, the patient is given general anesthesia for the procedure, and
the incisions are made in the lower abdomen after sterilizing the area. The surgeon must be
careful to remove every piece of the ovaries and tubes, especially in the case of a cancer, and
then the incisions will be closed and the patient will be moved to recovery.
COMPLICATIONS

Hemmorrhage
DVT
Bladder dysfunction
Infection

HEALTH EDUCATION

Pain

Your doctor will give you a prescription for pain pills. When you have less pain, you may prefer
to take plain Tylenol. If you find that an activity gives you pain, stop and rest. Wait a few days
before trying that activity again. Walking and moving around can help with the shoulder pain
from the gas.

Activity

For several days after your surgery, your activity will be less than normal. Do light activities
during the first week after surgery. This can be walking or your daily house activities. You will
be able to climb stairs. Moving around reduces the chance of a clot forming in your legs and will
rebuild muscle strength. You will use a lot of emotional energy during this time. Rest and
relaxation will help your recovery. Activities you enjoy will also renew your energy and sense of
wellbeing.

Do not do activities that use a lot of your stomach muscles for 3 to 4 weeks after surgery. These
include: heavy lifting greater than 5 kgs or 10 lbs vacuuming or pushing a lawn mower
weight training high impact sports

Shower

You may shower the day after surgery. Gently pat dry your incisions. Do not take a bath for 3
days after surgery. Do not douche until your doctor allows you to. The small steri-strips on your
wounds will come off by themselves. If they begin to fall off, you can pull them off without any
worry. If they have not come off 2 to 3 days after surgery, please remove them gently. The
stitches will dissolve on their own. The stitches underneath will dissolve on their own. If the
stitches feel like they are getting caught on your clothing, you may cover them with a dry
bandaid. Do not apply polysporin products to the area without direction from your health care
team.

Eating

Slowly return to your normal diet over a few days. Drink plenty of fluids. Healthy eating can
help give you energy and strength. A balanced diet of protein, fruit, vegetables and whole grains
will help your body heal. Your diet can also prevent problems with constipation. Eat foods with
fibre such as bran, whole grains, fruits and vegetables to keep your bowels healthy and regular.

Sex

You should not have sexual intercourse until your doctor has examined the top of your vagina
after surgery to make sure it has healed properly. Of course, affection and touching are possible
before that time if you wish. Most women report few sexual changes as a result of this surgery,

Follow-up visits

Make sure that you have a follow-up appointment about 4 weeks after surgery. This
appointment is to check that you have healed well after surgery, to review the pathologists
report and to discuss whether any further treatment is needed.

Come immediately to hospital if you have:

bright red vaginal bleeding that is like a period

foul smelling vaginal or wound discharge

a fever of 38.3oC (101oF) or higher

pain that gets worse despite taking pain medication

not been eating and drinking, you feel sick to your stomach and are vomiting

redness or increased pain around your incisions

a full or bloated abdomen

episodes of fainting

SUMMARY

In this we delt with carcinoma ovary, anatomy and physiology,causes, sign and symptoms,
management, diagnosis, complications and health education

CONCLUSION

The ovaries are part of the female reproductive system. They produce a woman's eggs and
female hormones. Each ovary is about the size and shape of an almond.Cancer of the ovary is not
common, but it causes more deaths than other female reproductive cancers. The sooner ovarian
cancer is found and treated, the better your chance for recovery. But ovarian cancer is hard to
detect early. Women with ovarian cancer may have no symptoms or just mild symptoms until the
disease is in an advanced stage. Then it is hard to treat.Siraja Begum is developed cancer ovary
in a peroid of time. Now she is admitted for surgery.Routine diagnosis is going on .Date is not
finalised since she is suffering from fever.

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