Project in RLE

2
Nasopharyngeal Carcinoma
(Documentation in RLE 2)

Submitted to:
Mrs. Cristine Maalat

Submitted by:
Group V
BSN-II Block 2

Agustin, Sheena
Alao, Jessica
Asakawa, Tomohiro
Balamban, Krishiel
Balbon, Jenny
Ballaho, Ahmad
Balodong, Brenda
Bautista, Bryan
Baylon, Josephine
Bermal, Zanesa
Berso, Robbylyn
 Cardiño, Joanne

A Documentation Presented to the Faculty of Level II

College of Nursing
Arellano University – Pasay Campus

In Partial Fulfillment of the Requirements in RLE 2

Submitted to:
Mrs. Cristine Maalat
Clinical Instructor

Submitted by:
Group V
BSN-II Block 2

Agustin, Sheena Balodong, Brenda

Alao, Jessica Bautista, Bryan
Asakawa, Tomohiro Baylon, Josephine
Balamban, Krishiel Bermal, Zanesa
Balbon, Jenny Berso, Robbylyn
Ballaho, Ahmad Cardiño, Joanne
I. ASSESSMENT

A. General Data

Patient’s Name: Mr. Romeo Ramos Sex: Male

Address: 55B Bronze St., Tucong, Malabon City Civil Status: Married

Age: 48 yrs. old

Date of Birth: March 23, 1958 Place of Birth: Manila

Citizenship: Filipino Religion: Roman Catholic

Admitting Physician: Dr. Mandapat Medication: Tramadol

Diagnosis: Nasopharyngeal Carcinoma (Stage IV)

B. Chief Complaints

Inability to urinate, body pain

C. Vital Signs

Temperature: 35.8ºC

Blood Pressure: 140/100 mmHg

Respiratory Rate: 10 cpm

Pulse Rate: 71 bpm

D. History of Present Illness

According to the patient’s companion, there is a history of cancer among the

patient’s family. One of Mr. Ramos’s cousins died of brain cancer.

The patient used to work as a welder and construction worker. He used to

smoke but he consumed only a few sticks of cigarettes everyday. He was a social
drinker and was not prone to drinking binges. He consulted a doctor because he had a

cyst on the back of his neck.

The patient was diagnosed with Nasopharyngeal Carcinoma in the year 2003 in

Philippine General Hospital. He has undergone chemotherapy six (6) times, as well as

Cobalt therapy.

Mr. Ramos has been bedridden since November 2006.

The patient is usually confined in PGH but last January 23, 2006 the family

decided to have him confined at PGH due to his inability to urinate but they were told

to go home because PGH was full and there were no scheduled treatment for him. He

was then admitted to PBM and the doctor ordered that the patient be connected to a

catheter. His present medication is Tramadol. He is under no food restriction. The

patient eats often but only in small amounts. He uses the nebulizer whenever he has

difficulty breathing.

E. Physical Examination

Vital signs:

Temp: 35.8°C (hypothermic)

PR: 71 bpm

RR: 10 bpm

BP: 140/100 mm/Hg

BM: Once a week, solid but only in small amount.

Regional Examination:
Skin
 The patient is very dry-skinned.
 Skin is cold and clammy.
Hair
 Client has thick and short hair but his scalp has flakes.

Head and Face

 Client’s head is normocephalic.
 He has hollow cheekbones.
 Eyes

 Eyelids: no swelling, discharges and lesions.

 Eyes are proportional to the size of face, oval, and dark brown in color.

 Eyes are symmetrical, no involuntary movement, no swelling.

 Eye movements are coordinated, full EOM.

Ears

 Color is the same as the surrounding area.

 Symmetrical, parallel, proportional to the size of head and in bean-shaped

helix.

 Ear canal is partially dirty, with accumulated cerumen.

 Able to hear whispered words.

Nose

 Client’s nose is parallel and proportion to the size of the head.

 No discharge or secretion was observed with no lesions.

Mouth

 Lips are very dry.

 No bleeding.

 The client has difficulty in swallowing.

 Noted foul breath odor.

Neck
  Patient has dark spots on his neck which was a result of Cobalt therapy, 8.5 cm
11.5 cm in dimension.

 There is a cyst on the back area of the patient’s neck.

Thorax

 The bones of the patient’s thorax are already prominent due to the patient’s

thinness.

 Observed difficulty in breathing and chest retraction.

 Bradypnea as observed. RR is only 10 cpm.

Other Observations:

 Patient is very thin and his bones are already protruding especially on his upper

and lower extremities

 The patient has extended veins.

 Patient is non-edematous.

 Assymetrical structure of palms, left palm is long and slim while right palm is

long but plumper.

 Muscle atrophy

 Cracked heels

F. Past History

1. Childhood Illness – none

2. Adult Illness- Nasopharyngeal Carcinoma,

3. Immunization- cannot remember

4. Previous Hospitalization- Philippine General Hospital

5. Operation- none
 6. Injuries- none

7. Allergies- NKA

Nasopharyngeal Carcinoma

Fig 1. Image of a patient with Nasopharyngeal Carcinoma

Nasopharyngeal cancer is a disease in which malignant (cancer) cells form in

the tissues of the nasopharynx. It most commonly starts in the squamous cells that line

the oropharynx. Nasopharyngeal carcinoma cases occurs much more frequently found

in Southeast Asia and northern Africa. Men are more likely than women to develop the

disease. It's most commonly diagnosed in people from age 30 to age 60, though

nasopharyngeal carcinoma can also occur in older adults and in children.

PATHOLOGY

Nasopharyngeal carcinoma is a lymphoepithelioma comprising lymphoid elements

admixed with malignant epithelial cells identical to those of a poorly differentiated

squamous cell carcinoma. The epithelial cells, not the lymphoid elements, are

considered neoplastic.
Biopsy is necessary to differentiate nasopharyngeal carcinoma from other

nasopharyngeal malignancies, such as:

• lymphoma - including Burkitt's lymphoma

• sarcoma - rhabdomyosarcoma, sarcomas from fibrous, cartilaginous, or osseous

tissues surrounding the nasopharynx

• adenocarcinoma

• tumours from salivary tissues - such as adenoid cystic adenocarcinoma

Spread may occur:

• directly:

o anteriorly, i.e. nasally

o inferiorly, i.e. pharyngeal

o superiorly, i.e. sphenoidal

o posteriorly, i.e. region of first cervical vertebra

o laterally, i.e. parotid gland; IX, X, XI, XII cranial nerves

• lymphatic - to the upper deep cervical lymph nodes

• haematogenous - to the spinal column, lung and liver

EPIDEMIOLOGY

• the total incidence of mouth, lip and pharyngeal cancer is approximately 3,600

cases per annum

• clinical presentation of nasopharyngeal cancer:

o neck lump 80-90%

 o nasal obstruction 60%

o deafness 50%

o postnasal discharge 40-50%

It is difficult to diagnose cases of nasopharyngeal carcinomain it’s early stages

because the disease causes signs and symptoms that may suggest a variety of diseases

and conditions. In addition to that, the nasopharynx is located in a hidden location. This

means most people aren't diagnosed with nasopharyngeal carcinoma until the cancer

has spread. This is unfortunate because nasopharyngeal carcinoma becomes more

difficult to treat when it becomes more advanced.

In many cases, it isn't clear what causes the gene mutations that lead to

nasopharyngeal carcinoma, though risk factors that increase the risk of this cancer have

been identified. Instances occur wherein people with all the risk factors never develop

cancer, while others who have no apparent risk factors do and the reason for this is still

not clear.

CLASSIFICATION

The World Health Organization has developed a classification system that divides

nasopharyngeal carcinomas into three types based on light microscopy findings.

 Type I or Squamous cell carcinomas are characterized by moderate to well

differentiated cells that produce keratin and have intercellular bridges and other

findings similar to typical squamous cell carcinomas. Twenty-five percent of

nasopharyngeal carcinomas are of this type.

  Type II lesions, non-keratinizing carcinomas, have cells that vary from mature

to anaplastic in appearance but produce minimal if any keratin. These

carcinomas often resemble transitional cell carcinoma of the bladder.

Approximately twelve percent of nasopharyngeal carcinomas are of this type.

 Type III comprises a diverse group of carcinomas often described as

undifferentiated carcinomas. Included in this group are lymphoepitheliomas,

anaplastic, clear cell, and spindle cell variants. These lesions are often difficult

to differentiate from lymphoma and may require special stains and markers to

identify their epithelial origin. The tumor cells are often located in a lymphoid

stroma and when the density of the stroma is greater than the tumor cells

themselves, the lesion is termed a lymphoepithelioma.(2) Sixty percent of all

nasopharyngeal carcinomas and nearly all of those found in young patients are

of this type.

Risk factors

 Salt-cured foods

 Preserved meats

 Epstein-Barr virus.

 Family history

Nasopharyngeal carcinoma isn't as closely linked to smoking and excessive

alcohol use as most other head and neck cancers are.

 Possible signs of nasopharyngeal cancer include:trouble breathing, speaking, or

hearing. Signs and symptoms of nasopharyngeal carcinoma may include:

 A lump in the neck caused by a swollen lymph node

 Bloody discharge from the nose/Nosebleeds

 Nasal congestion on one side of your nose

 Hearing loss in one ear / trouble hearing

 Pain or ringing in the ear

 Frequent ear infections

 Headaches

 Double vision

 Face and neck pain

 A feeling of fullness in the throat and sinus areas

 A sore throat.

CLINICAL FEATURES

Common features of nasopharyngeal carcinoma are:

• bilateral cervical node enlargement - in one third of cases

• nasal voice, epistaxis, possibly, nasal obstruction - in one third of cases

• deafness from Eustachian tube involvement - in one fifth of cases

The exact presentation however, depends on the location and spread of the tumour.

They may be grouped as:

 • features of local disease:

o nasal - postnasal obstruction; unilateral or bilateral nasal obstruction;

loss of smell; epistaxis; blood stained nasal discharge

o aural - secretory or less commonly, suppurative otitis media; deafness;

otalgia; tinnitus; rarely, ear discharge

o orbital - proptosis; restricted eye movement; diplopia; impaired vision;

rarely, blindness

o pharyngeal - difficulty in speaking; dysphagia; excessive salivation;

airway obstruction

• neurologic - cranial nerve involvement at the skull base. Most commonly, III,

IV and VI, and IX, X, XI and XII with trigeminal involvement

• neck metastases - unilateral or bilateral, often asymmetrical, enlargement of the

upper deep cervical lymph nodes

Constitutional features suggest advanced disease - pain; headache; nausea; vomiting;

anorexia; and loss of body weight; in severe cases, cachexia

To diagnose cases of nasopharyngeal cancer tests that examine the nose and throat

are used. The following tests and procedures may be used:

 Physical exam of the throat

 Nasoscopy

 Neuro/Neurologic/Neurological Exam

 Head and chest x-rays

  MRI (Magnetic Resonance Imaging)/NMRI (Nuclear Magnetic Resonance

Imaging

 CT Scan (Computed Tomography)/CAT Scan (Computerized Axial

Tomography)

 PET Scan (Positron Emission Tomography Scan)

 Laboratory tests: Medical procedures that test samples of tissue, blood, urine, or

other substances in the body. These tests help to diagnose disease, plan and

check treatment, or monitor the disease over time.

 Biopsy

After nasopharyngeal cancer has been diagnosed, tests are done to find out if cancer

cells have spread within the nasopharynx or to other parts of the body. The process

used to find out whether cancer has spread within the nasopharynx or to other parts of

the body is called staging. The information gathered from the staging process

determines the stage of the disease. It is important to know the stage in order to plan

treatment. The results of the tests used to diagnose nasopharyngeal cancer are often also

used to stage the disease.

The following stages are used for nasopharyngeal cancer:

Stage 0 (Carcinoma in Situ)

 Cancer is only found in the lining of the nasopharynx. Stage 0 cancer is

also called carcinoma in situ.

Stage I
  Cancer is found only in the nasopharynx.

Stage II

Stage II nasopharyngeal cancer is divided into stage IIA and stage IIB as follows:

• Stage IIA: Cancer has spread from the nasopharynx to the oropharynx (the

middle part of the throat that includes the soft palate, the base of the tongue, and

the tonsils), and/or to the nasal cavity.

• Stage IIB: Cancer is found in the nasopharynx and has spread to lymph nodes

on one side of the neck, or has spread to the area surrounding the nasopharynx and

may have spread to lymph nodes on one side of the neck. The involved lymph

nodes are 6 centimeters or smaller.

Stage III

• The cancer is found in the nasopharynx and has spread to lymph nodes on both

sides of the neck and the lymph nodes are 6 centimeters or smaller; or

• has spread into the soft tissues (oropharynx and/or nasal cavity) and to lymph

nodes on both sides of the neck and the lymph nodes are 6 centimeters or smaller;

or

• has spread beyond the soft tissues into areas around the pharynx and to lymph

nodes on both sides of the neck and the lymph nodes are 6 centimeters or smaller;

or
 • has spread to nearby bones or sinuses and may have spread to lymph nodes on

one or both sides of the neck and the involved lymph nodes are 6 centimeters or

smaller.

Stage IV

Stage IV nasopharyngeal cancer is divided into stage IVA, stage IVB, and stage IVC as

follows:

• Stage IVA: Cancer has spread beyond the nasopharynx and may have spread to

the cranial nerves, the hypopharynx (bottom part of the throat), areas in and

around the side of the skull or jawbone, and/or the bone around the eye. Cancer

may also have spread to lymph nodes on one or both sides of the neck, and the

involved lymph nodes are 6 centimeters or smaller.

• Stage IVB: Cancer has spread to lymph nodes above the collarbone and/or the

involved lymph nodes are larger than 6 centimeters.

• Stage IVC: Cancer has spread beyond nearby lymph nodes to other parts of the

body

Recurrent Nasopharyngeal Cancer

Recurrent nasopharyngeal cancer is cancer that has recurred after it has been

treated. The cancer may come back in the nasopharynx or in other parts of the body.

Complications
 Nasopharyngeal carcinoma frequently spreads (metastasizes) beyond the

nasopharynx. Most people with nasopharyngeal carcinoma have regional metastases,

meaning cancer cells from the initial tumor have migrated to nearby areas, such as

lymph nodes in the neck. Cancer cells that spread beyond the head and neck (distant

metastases) most commonly travel to the bones and bone marrow, lungs and liver.

Nasopharyngeal carcinoma may also cause "paraneoplastic syndromes." In

these rare disorders your body's immune system reacts to the presence of cancer by

attacking normal cells. Paraneoplastic syndromes may cause high levels of certain

white blood cells in your blood, fever, neurologic problems or joint problems. Once

your cancer is treated, your doctor may prescribe medications to control your immune

system.

Treatment

The prognosis of nasopharyngeal carcinoma depends more upon the extent and

intensity of radiotherapy received rather than the stage of diagnosis; modern

supervoltage techniques may achieve 50% or more 5 year survival rates, whereas

previously, this may have been expected to be of the order of 10 - 30%.

Mortality usually results from intracranial extension, respiratory obstruction,

haemorrhage or cachexia.

Devising a treatment plan is based on several factors:

 There are certain factors which affect the chance of patients with the nasopharyngeal

CA. The prognosis and treatment options depend on the following:

 The stage of the cancer

 The type of nasopharyngeal cancer.

 The size of the tumor.

 The patient’s age and general health.

 The treatment goals

 The side effects that the patient is willing to tolerate.

Treatment for nasopharyngeal carcinoma usually begins with radiation therapy.

While surgery is the mainstay of treatment for many cancers, navigating the

nasopharynx with surgical tools is delicate. Nasopharyngeal carcinoma is particularly

sensitive to radiation therapy, making it the first line of treatment. Surgery and

chemotherapy are used in certain cases.

Radiation

Radiation therapy treats cancer with high-energy beams. Radiation therapy destroys

quickly growing cells, including cancer cells, in the area where the beams are focused.

It also targets areas close to the neck even if there's no evidence your cancer has spread

beyond your nasopharynx. This reduces the chance that the cancer will spread and the

recur.

Radiation therapy carries a risk of side effects, including hearing loss, dry

mouth, sores in the mouth and throat, and an increased risk of tongue cancer and bone
cancer. The nasopharynx is situated among some delicate organs, such as your brain,

spinal cord, thyroid gland, eyes and ears and there is a risk that these areas will be

unprotected to the radiation. Internal radiation therapy (brachytherapy) is sometimes

used in recurrent nasopharyngeal carcinoma. With this treatment, radioactive seeds or

wires are positioned in the tumor or very close to it.

Chemotherapy

Chemotherapy uses drugs to treat cancer. Unlike radiation therapy, which is focused on

one part of your body, chemotherapy travels throughout your body. Chemotherapy

works by attacking quickly growing cells, including cancer cells. Some healthy cells

are also killed by chemotherapy, which can cause side effects, including fatigue, hair

loss, and nausea and vomiting. Chemotherapy may be used to treat nasopharyngeal

carcinoma in three ways:

 Chemotherapy at the same time as radiation therapy (concomitant

therapy). Chemotherapy enhances the effectiveness of radiation therapy. Using

the two treatments together may reduce the need for high doses of radiation,

which reduces the side effects associated with radiation therapy. Chemotherapy

also reduces the risk that your body will become resistant to radiation therapy.

However, side effects of chemotherapy are added to the side effects of radiation

therapy, making concomitant therapy difficult to tolerate.

 Chemotherapy after radiation therapy (adjuvant therapy). Adjuvant

chemotherapy is used to attack any remaining cancer cells in your body,

including those that may have broken off from the original tumor and spread
 elsewhere. Some controversy exists as to whether adjuvant chemotherapy

actually improves survival in people with nasopharyngeal carcinoma. Many

people who undergo adjuvant therapy after concomitant therapy are unable to

tolerate the side effects and must discontinue treatment.

 Chemotherapy before radiation therapy (neoadjuvant therapy).

Neoadjuvant chemotherapy works in the same way as adjuvant chemotherapy,

but it's administered before radiation therapy alone or before concomitant

therapy. Some people find they experience fewer side effects if they undergo

chemotherapy before the rest of their treatment. However, little research has been

done on neoadjuvant chemotherapy, so it's considered experimental.

What chemotherapy drugs you receive and how often will be determined by your

doctor. The side effects you're likely to experience will depend on which drugs you

receive.

Surgery

Surgery is usually reserved for recurrent nasopharyngeal carcinoma. Surgery to remove

cancerous lymph nodes in the neck is the most common surgery for nasopharyngeal

carcinoma. Surgery to remove a tumor from the nasopharynx requires surgeons to make

an incision in the roof of your mouth in order to access the area.

Prevention

There is no known 100% effective way that exists to prevent nasopharyngeal

carcinoma. However, steps can be taken to reduce a person’s risk of the disease. For
example, you can cut back on the amount of salt-cured foods and preserved meats that

you eat, or avoid these foods altogether. The risk for cancer never completely goes

away, because there are other unknown or uncontrollable risk factors may play a role in

developing nasopharyngeal carcinoma.

Coping skills

Everyone deals with a cancer diagnosis in his or her own way. Patients should take

steps to empower themselves and control what they can about their health.

 Learn everything you can about the cancer

 Create a support network. Emotional support or any other kind of support

from family and friends is valuable.

 Take time to be alone when needed

 Take care of yourself.

 Choose a healthy lifestyle.

 Quit smoking.

 Eat a variety of fruits and vegetables.

 Get some exercise.

 Get enough sleep

 control stress by prioritizing

 Drug Study

Medication: Tramadol Capsule

Generic Name: Tramadol hydrochloride

CLASSIFICATIONS:

Therapeutic: Analgesics (centrally acting)

Pregnancy Category C

INDICATIONS:

 Moderate to moderately severe pain

ACTION

 Binds to mu-opioid receptors

 Inhibits re-uptake of serotonin and norepinephrine in the CNS

 Decreased pain

PHARMACOKINETICS

Absorption: 75% absorbed after oral administration

Distribution: crosses the placenta; enters the breast milk

Metabolism and excretion: mostly metabolized by the liver, one metabolite has

analgesic activity; 30% is excreted unchanged in urine

Half Life: Tramadol – 5-9 hr; active metabolite 5-9 hr (both are increased in renal or

hematic impairment.

CONTRAINDICATIONS AND PRECAUTIONS

Contraindicated in:

 Hypersensitivity

 Cross-sensitivity with opioids may occur

 Patients who are acutely intoxicated with alcohol, sedative/hypotonics, centrally

acting analgesic, opioid analgesics, or psychotropic agents

 Patients who are physically dependent on opioid analgesics (may precipitate

withdrawal)

Use cautiously in:

 Geriatric patient (not to exceed 300 mg/day in patients >75 years old)

 Patients with history of epilepsy or risk factors for seizures

 Renal impairment (increasing dosing interval recommended if CCr >30 ml/min)

 Hepatic impairment (increased interval recommended in patients with cirrhosis

 Patients receiving MAO inhibitors or CNS depressants

 Increased intracrimal pressure or head trauma

 Acute abdominal conditions (may preclude accurate clinical assessment)

 Patients with history of opioid dependence or who have recently received large

doses of opioids
  Children below sixteen (16) years old (safety not established)

ADVERSE REACTIONS AND SIDE EFFECTS

 CNS: dizziness, headache, somnolence, anxiety, CNS stimulation, confusion,

coordination disturbance, euphoria, malaise, nervousness, sleep disorder,

weakness

 EENT: visual disturbance

 CV: vasodilation

 GI: constipation, nausea, abdominal pain, anorexia, diarrhea, dry mouth,

dyspepsia, flatulence, vomiting

 GU: menopausal symptoms, urinary retention/frequency

 Derm: pruritus, sweating

 Nuero: hypertonia

 Misc: physical dependence, psychological dependence, tolerance

INTERACTIONS

Drug-drug:

 High risk of CNS depression when used concurrently with other CNS

depressants, including alcohol, antihistamines, sedative/hypotonics, opioid

analgesics, anesthetics, or psychotropic agents

 High risk of seizures with high dose of penicillins, or cephalosporins,

phenothiazines, opioid analgesics, or anti depressants

  Carbamezapine high metabolism and low effectiveness of of tramadol (increased

doses may be required.

 Use cautiously in patients who are receiving MAO inhibitors (high risk of

adverse reactions

 Effectiveness may be countered by concurrent quinidine.

Drug-Natural Products

 Concomitant use of kava, valerian or chamomile (CNS Depression)

ROUTE AND DOSAGE

 PO (Adults) –

 50-100 mg q 4-6 hr (not to exceed 400 mg/day or 300 mg in patients

>75 years old)

 Gradually titration – 25 mg/day initially increase by 25 mg/day every

three days to 100 mg/day, then increased by 50 mg/day every 3 days up

to 200 mg/day

AVAILABILITY

 Tablets: 50 mgRx

 Acctminophen (ultracct)