Ain Shams University

Faculty of Nursing
2nd term Master
2014

Case study about

Patient with

"Gastric Cancer"

Prepared by:Wafaa Hamdy Mohammed atta

Under supervision of:Prof. Dr / Olea

Objectives
At the end of this case study, I will be able to:
General objectives:
To provide the patient with high quality of care based on
accurate assessment & scientific knowledge.
Specific objectives:
1. To perform patient assessment.
2. To acquire knowledge about disease process and its
complication.

3. To accept acquire knowledge about disease process

and its complication.
4. To gain knowledge about ideal nursing care plan for
this patient.
5. To establish goals or outcome criteria.
6. To implement the stated nursing care plan to
achieve expected outcomes.
7. To provide the patient health education
&rehabilitation after return to home.

Out lines:1. Reasons of patient selection.

2. Introduction.

3. Epidemiology.
4. Overview one the anatomy and physiology of the affected system.
5. Patient Demographic data.
6. Past and present Medical history of current illness.
7. Comparison between patient disease, which already clinically
present and what in the textbook.
Including The high-risk group and age.
Common site.
Predisposing factors (Causes).
Patho physiology.
Clinical Manifestations.
The Diagnostic Evaluations.
Diagnostic procedures.
Laboratory Investigations.
The complications.
The Management.
Medical Management.
Surgical Management.
Nursing Management.
6) Comprehensive Nursing care plan for the patient for already
clinically existed Health problems.
7) Rehabilitation program for this patient.

Reasons for patient selections: The patient case was critical, reached to a serious complicated
late stage of disease "Cancer stages" and He Needs for
comprehensive Nursing care more than other patient was.
I am interested in this patient's Diagnosis studying and
making a correlation between the textbook and what really
with the patient case.
The affected system "Digestive system "stomach" is more
sensitive human body part Need for specific consideration.

Introduction:
95% of gastric cancers are adenocarcinomas.
The remaining 5% are lymphomas (second most common, includes
MALT
lymphomas), sarcomas (including leiomyosarcomas and Kaposis
sarcomas),
GISTs, carcinoids, and squamous cell carcinomas
2 distinct histologic subtypes of gastric adenocarcinomas: intestinal,
diffuse

* Intestinal type retained glandular structure, more localized

* Diffuse type no glandular structures, more spread out

Epidemiology
Worldwide: fourth most common cancer, 2nd leading cause of
cancer death
In the US: 14th most common cancer, 7th most common cancer
death
Incidence of intestinal type has declined rapidly over the recent few
Decades? Due to invention of refrigerators, with better food storage
and
Reduced need for salt-based preservation.
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 Incidence of diffuse type has declined more gradually

Incidence of diffuse type has declined more gradually
Incidence of distal gastric cancers has decreased, but proximal
(cardiac)
Cancers have increased (some propose that these cancers are a
separate
Entity, more closely resembling Barretts associated esophageal
adenocarcinoma).

Overview on the anatomy and

physiology of the affected part
"stomach"

 It is located on the upper left quadrant of the abdominal cavity to

the left of liver and in front of the spleen.
It is a hollow muscular organ.
Although it is a part of the alimentary canal, it is not a tube but it is
a sac extend from the esophagus to the duodenum of small
intestine.
The stomach is consisting of three parts fundus, body and pylorus.
It has two sphincters

Cardiac sphincter with esophagus.

Pyloric sphincter with duodenum.

It has four layers "lining layers".
1) Mucous membrane contain glands, which secrete Digestive
juice as pepsinogen and Hcl.
Those glands called gastric pits.
2) Sub mucous coat, which contain blood capillaries and hold
layers together.
3) Muscular layer which responsible for peristalsis motion.
4) Fibrous layer which line the peritoneum cavity.
The stomach has mucosa appeared wrinkled, folded when be empty
called Ruga which flattened out and be expanded as the stomach is
filled with foods.
The stomach store and mixes food with gastric secretions as Hcl.
Not only for Digestion "Breaking Down to be more absorbable
component mainly Digestion of proteins and production of intrinsic
factor which needed for vit Biz absorption in ileum"
In addition, aid in destruction of most ingested bacteria.
The Digestion process on the stomach influenced by Gastric
secretions and gastric motility which regulated bya) Hormonal Regulation:As Gastrin which stimulated by gastric distention by food.
Stimulate gastric glands to increase secretion
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Of gastric, juice mainly Hcl.

Increase motility, constriction of cardiac sphincter
In addition, Relaxation of pyloric sphincter.
b) Neuron - Regulation: Para - sympathetic "A cetyle choline"
Stimulated by sight smelling of foods, chewing
Alternatively, stomach distention
Stimulate gastric gland to secrete gastric acids
And increase or decrease sphincter tone.
c) Local Regulator as Histamine: which stimulate gastric gland to
increase gastric acid production.

The patient Demographic Data: Patient Name: Shehata Mohammed Mohammed.

Age: 74 years.

Sex: Male.

Education :Illiterate
Religious: Muslim
Occupation: farmer
Marital status: Married and has three siblings (2 sons and
daughter).
Date of admission: 10/4/2014.
Admitted from: outpatient department (OPD).
Stay period: 15 day.
Prsent History :

Diagnosis/ Present illness: Gastric Cancer

 Reasons of admission : "Chief complains"

* Severe abdominal pain in left upper Quadrant.
* Persistent sever vomiting.
Associated signs and symptoms
*loss of appetite.
* Palpable gastric Mass.
*Noted marked loss of weight leading to cachexia.
Onset / Duration / Frequency:
The patient condition started from 8 months ago with
persistent vomiting then patient developed
Hematemesis (Fresh blood) with palpable gastric
Mass
Predisposing factors: diet rich with salted smoked
food.

Low fruits Diet intake.

Excessive Heavy smoking for more than 20 years

-Reliving measures and its effect:

History: Medical:
-Diagnosis / Duration:

From 2 years ago the patient felt with sever pain in the left leg
combined e pale to white color of extremities and very weak
peripheral pulse on this limb.
CT angiography was made for the patient left limb, which was
revealed with thrombotic occlusion of left external iliac / left
common femoral artery.
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 "Gastric Carcinoma" took Revealed endoscopic Biopsy.

Abdominal C-T was done Revealed by
Hepatic focal lesion.
Prostatic enlargement.
Left Rectus sheath lipoma.

Medical Diagnosis: Pyloric obstruction secondary to antral malignant mass

Metastatic to liver.
Alternatively, Gastric Adeno-carcinoma e liver Metastasis.
The Medical staff Decided that the patient not fit for surgery,
chemotherapy, or Radiotherapy.
And He Need for palliative Medical care as
Hydration with continuous I.V fluids.
Antacids Medication and anti-emetics.
Pain killers As Tramadol.
Bone scan.
Surgical:
Name of surgery / Durationtonsillectomy at age of 15yrs
Allergy history: NO
Family history: D.M.
-Diagnosis / Relation: his mother.
Life style habit: Diet rich with salted smoked food.
Low fruits Diet intake.
Excessive Heavy smoking for more than 20 years
Patients physical assessment
1- Respiratory system sever dyspnea.
Mild pleural effusion with crackles chest sound.
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2-Cardio-vascular system Anemia.

3-Peripheral vascular absent femoral and dorsalis pedis pulses of
the left leg.
4-Neurological assessment sever back pain, Tender upper dorsal
spine.
Drowsiness.
Agitation and irritability.
5-Gastro-intestinal system:
Palpable enlarged stomach with succession splash

Sever excessive blackish vomitus.

Chronic constipation.
Mild hepatomegaly as ametasis to liver.
6-Urinary system Oliguria and dysuria.
7-Musculoskeletal system
Malaise and easily fatigability.
Mobile with assistance of other
8- Skin assessment:
*poor skin turger
*pale in color
*hot and dry skin
9- Head\hair-----10-Eyeswear eyeglasses
11-Ears
12Nose-----------------------------------------------------------------------------------------

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13Mouth--------------------------------------------------------------------------------------14- Neck: short neck

15- Activity and rest: limited activity due to age change and his
illness.

Definition of disease: abnormal and unregulated growth of the

cells that make up the stomach.

group Risk High (1)

Comparison between patient disease,

which already clinically present and
what in the textbook:
Men have high incidence of
gastric cancer than woman

The patient is 74 years

old

The occurance incidence

between 40 70 years of age.

He has No familial
History of cancer.

There is No validated
Gastric cancer has high
incidence with patient has familial check up for genetic liability
or Not.
history of GI.T cancers
Alternatively, who has genetic
liability as Mutation of "Tumor
suppressor gene"?

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site Common (2)

factors posing Predis (3)

Pylorus or antrum and adeno

carcinoma.

Gastric out let "Pyloric"

obstruction 2nd ry to
malignant antral Mass.

Diet high rich with salted

smoked pickled foods.

Diet high rich with salted

smoked food.

Chronic Inflamation of the

stomach.

Low fruits Diet intake.

Helico-bacterial Infection.

Excessive Heavy smoking

for more than 20 years.

Low fruits-vegetable diet

intake.
Perincious anemia.
achlorhydria.
Smoking.
Genetic liability.

physiology (4) Patho-

Previous subtotal gas trectomy.

* Most gastric cancers are Adeno- * The patient has Adenocarcinomas occur on any portion carcinoma Metastatic to the
then infiltrated to the surrounding liver.
mucosa.
* The liver pancrease
esophagus and duodenum are the
most affected sites at time of
diagnosis.

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* Early stage of gastric cancer

symptoms pain relieved by
* Progressive late stage of

* The patient had

developed the progressive
symptoms of gastric
cancer.

disease symptoms are :-

Severe abdominal pain.

Dyspepsia (Indigestion).
Anorexia e early satiety.

Sever excessive blackish

vomiting.

Weight loss.

Loss of appetite.

Severe abdominal pain (bloating

after meals) Nausea vomitingconstipation anemia.

sever weight loss

n estatio Manif al Clinic (5)

Antiacids as benign ulcers.

cachexia
Chronic constipation.
Anemia.
Palpable gastric Mass.
Malaise and easily
fatigability.
Drowsiness.
Dyspnea.
Agitation and irritability.

(A) * Physical examination : Advanced gastric cancer may be

with palpable Mass.
Ascites and hepato megaly as a
metastasis to liver.
Palpable Nodules around
umbilicus called Sister Marry
Joseph's Nodule are a sign of GIT
Malignancy.

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(A) * Patient has palpable

gastric "upper left" Mass.
* Patient has Mild
Hepatomegaly and Mild
pleural effusion.

(B)* Diagnostic procedures :1) Esophago gastro duodena

scopy for Biopsy and cytology
washing.

(B) * Endoscopic Biopsy was

taken from patient, which
referred with "gastric
carcinoma".

* Upper GIT Endoscopic

ultra sound Revealed with
gastric outlet obstruction 2
3) Endo scopic ultra sound
ry to Malignant antral
for limiting depth and lymph node Mass.
involvement.
* Abdominal C.T was Made
4) Computed Tomography on
Revealed with
abdomen / chest / pelvis
Hepatic focal lesion.
To detect staging of gastric
Enlarged prostate.
cancer.
Left Rectus sheeth
5) Bone scan to detect Metastasis
lipoma.
to the Bone.

(6) Diagnostic evaluations

2) Barium X-Ray of upper G.I.T

Tract.

(C)* Laboratory
Investigations:-

Investigation
WBC

Results
710^9/L

Tumor Markers as

RBC

3.510^12/
L
9.5g/dl

Alpha feto protein.

HG

Carbohydrate antigen.
C.B.C
Liver function and Renal
function.
Coagulation profile.
Arterial Blood gases.
Electrolytes Investigation.

PLATELETS 25910^9/
L
LDL
93mg/dl
SGPT
45U/L
SGOT
54U/L
PT
PTT
Bilirubin

14

13.60
28.4
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ication Compl (7)

* Metastasis to the surrounding

abdominal organs as liver
pancrease esophagus small
intestine.
* Metastasis through lymphatic
system to the peritoneal cavity
then to kidney or Brain or Bones.

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* The pt developed
Metastasis to the liver
"hepatic focal lesion"

(A) * Surgical Management : A total gastrectomy for

aresectable tumor on the Mid
portion or body of the stomach.

t gemen Mana (8)

The entik stomach is removed

with lower portion of esophagus
and supporting mesentery and
lymph nodes.
Reconstruction of G.I.T
performed by Anastomosis
between esophagus and jugenum
"esophago Jejunostomy"
A radical subtotal gastrectomy
is performed for Respectable
tumor in the middle and distal
portion of the stomach.
A proximal subtotal
gastrectomy for Respectable
tumor in proximal portion of
stomach or cardiac.
Palliative procedures As gastric
or esophageal bypass /
Gastrostomy / jejunostomy
alleviate symptoms as Nausea,
vomiting.
If there is Metastasis to liver to
achieve better quality of life.

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(A) The pt had not made

(Received) any surgical
Intervention according the
medical staff opinion as he
is not fit for any surgical
intervention.

(B) * The pt hadn't :receive any chemo-Radio

Chemotherapy :- if surgical
therapy According to the
Not offer cure As palliative
Medical staff opinion "The
single agent chemo therapeutic pt is not fit for "Chemomedication Include
Radio therapy"
Fluoro uracile

(B) * Medical Management :-

Cisplatin "platinol"
Adriamycin.

Etopophos.

Mutamycin.
Radiotherapy: - mainly used as
palliation for pt with obstruction,
sever bleeding, sever pain
secondary to tumor.

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