Nasopharyngeal Carcinoma

Prepared by: BishlyCase Study

1Demographic DataCASE NO:14xxxNAME:Baby HAGE:3 yrs oldSEX:MaleDIAGNOSIS:Intussusception

Physical Assessment

Vital Signs:BP- 90/60HR- 126 bpmRR- 26/ minT- 38.5 CSPO2- 98%

General AssessmentPatient is conscious, coherent and oriented.Cries intermittently and recovers from pain

SkinNo lesion, moist and good turgorPale in appearance

Head and NeckNo palpable lesion on the head and neck.

ThoraxTrachea in centralChest movement are equalAir entry is equal in all areas, no added sound

AbdomenNo distention, no dilated veinsGuarding present, no rigidity in the right hypochondriumTenderness on the right hypochondriumNo free fluid on percussionBowel sound is present

GenitaliaCircumcisedTestes are bilateral descended and normal in size

No neurologic defect seen Neurological

Medical History

Past Medical HistoryThe patient has no major medical problemsNo history of surgery

Present Medical HistoryPatients chief complaints include colicky abdominal pain associated with fever for 2 daysPatient was seen by Dr. Jacob and was advised for ultrasoundOn examination: Febrile (Temp- 38 C) RR-20/ min SPO2- 97 % WT- 13 kg PR- 112 bpm Child cries intermittently and recovers from the pain Ultrasound done (shows doughnut- like image-target sign)

Topic presentationINTUSSUSCEPTION

IntroductionIntussusception is a term derived from the Latin intus (within) and suscipere (to receive). One segment of the bowel (intussusceptum) invaginates into another (intussuscepien) just distal to it, much like the piece of a telescope. When this occurs the bowel wall distends and obstructs the lumen. Peristalsis is disrupted leading to colicky abdominal pain and vomiting. Lymphatic and venous obstruction occurs, causing ischemia. In most children the intussusceptions is ileocaecal, although ileo-ileocolic and ileo-ileal or colocolic cases can occur.The male-to-female ratio is approximately 3:2.Two third of patient are under one year old, the peak age being between 5-10 months old.Intussusception is the most common cause of intestinal obstruction in patient aged 5 months- 3 years and accounts for up to 25 % of abdominal emergencies in children up to age 5.

Anatomy & Physiology

ETIOLOGY AND PATHOPHYSIOLOGY1. The cause can fall into one of the three categories: Idiopathic, Lead point, or Post operative.Idiopathic: this is the most common type, which no identifiable cause. It is not unusual, however, to obtain a history of a recent upper respiratory or GI virus. It is hypothesized that hypertrophy of Peyers patches create a thickened segment. Its most common in infants.Lead point: an identifiable change in the intestinal mucosa can be discovered, usually during surgical treatment and is most common in children ages 2-3. Malformations including polyps, cysts, tumors, Meckels diverticulum, and hematomas. Children with cystic fibrosis are at risk for lead point intussusceptions.Postoperative: uncommon but can occur after surgery of the abdomen and even the chest. It may be due to interrupted motility from anesthesia or direct handling of the intestine. It can also occur from placing long tubes into the bowel.

Cont.2. Invagination results in complete intestinal obstruction.Mesentery/ lymphatics/ blood vessels pulled into intestine when invagination occurs.Intestine becomes curved, sausage like; blood supply is cut off.Bowel begins to swell; hemorrhage may occur.Necrosis of the involved segment occurs.If not recognized or treated, bowel death occurs, possibly resulting in significant loss of intestine, shock and death.

3. Classification of location:Ileocecal (most common): when the ileum and the attached mesentery, lymphatic tissue, and blood vessels invaginates into the cecumIleocolic: ileum invaginates into colon.Colocolic: colon invaginates into colon.Ileo-ileo (enteroenteric): small bowel invaginates into small bowel.

Normal Intestine

Idiopathic: UNKNOWN- covers >90% of cases- viral 50%-rotavirus, adenovirus, Peyers patch hypertrophy

Decreased blood supply & eventually cuts off. Intestine becomes curved, sausage like, and bowel begins to swell Invagination results in complete intestinal obstruction. Lead Point:-Polyps, cysts, tumors, diverticulum and hematomas

Post-operative: Uncommon-Due to interrupted motility from the anesthesia or direct handling of the intestine.PathophysiologyMedical and Surgical treatment/ intervention done. Air/ Barium Enema Surgical ReductionDEATHShockPatient recoversNecrosis of involved segment occurs may result to bowel death, leading to significant loss of intestineSigns and SymptomsIt is usually of sudden onset, and may be more insidious in the older child.There are paroxysms (about every 10-20 minutes) of colickyabdominal pain(>80%) crying.The child may appear well between paroxysms initially.There is early vomiting - rapidly becoming bile-stained.Neurological symptoms such as lethargy, hypotonia or sudden alterations of consciousness can occur. There may be a palpable 'sausage-shaped' mass (often in the right upper quadrant).There may be absence of bowel in the right lower quadrant (Dance's sign).Dehydration, pallor, shock.Irritability, sweating.Later, mucoid and bloody 'red currant stools'.(Currant jelly stool indicates damage to the intestine and can be a late sign. )Late pyrexia.

Diagnostic TestCBC - may show neutrophilia.U&Es - may reflect dehydration.Abdominal X-ray - may show dilated gas-filled proximal bowel, paucity of gas distally, multiple fluid levels (but may be normal in the early stages).Ultrasound - may show doughnut or target sign, pseudokidney/sandwich appearance. It is a very effective modality and many consider it the investigation of choice. Bowel enema - barium has been gold standard (crescent sign, filling defect) but air and water-soluble double-contrast now available; each has pros and cons - the choice is left to the individual radiologist. CT/MRI scanning - more often used in adults than in children.

Abdominal X-RayAbdominal UltrasoundTreatments

1. Air Contrast Enema

A small tube is placed in the rectum and air passedthrough the tube. The air travels into the intestine andoutlines the bowel on the X-rays. If intussusception ispresent it will show the telescoping piece in theintestine. At the same time the pressure of the air unfolds the bowel that has been turned inside out and instantly cures the blockage. Air enema uses 24 hours)High likelihood of pathological lead pointFailed enema

3. Surgical Intervention

Pre- operativeObserve behavior a indicator of pain; the infant may be irritable and very sensitive to handling or lethargic or unresponsive. Handle very gently.Encourage family to participate it comfort measures. Explain cause of pain, and reassure the parents as to purpose of diagnostic test and treatments.Administer medication as prescribed.Monitor fluids, and maintain NPO status.Restrain infant as necessary for I.V. therapy.Monitor intake and output. Be alert for respiratory distress because of abdominal distention. Watch for grunting or shallow and rapid respirations if in shock like state.Insert NGT if ordered to decompress stomach.- Irrigate at frequent intervals.- Note drainage and return from irrigation.Maintain NPO status as ordered.- Wet lips, and perform mouth care.- Give infant pacifier to suck.Continually reassess condition because increased pain and bloody stool may indicate perforation.

Nursing Intervention:

Post- operativeMonitor vital signs and general condition, notify healthcare provider of any changes or unexpected trend.Assess temperature and administer antipyretics and other cooling measures. Fever is usually present from absorption of bacteria through the damaged intestinal wall.Assess for abdominal tenderness, bowel sounds, and distention of abdomen. Maintaining suction as ordered.Assess pain and level of consciousness.When able to take fluids, assess tolerance carefully and advance intake slowly.

ComplicationsMissed diagnosisIschemia of the intussusceptum/intussuscipiensNecrosisHemorrhagePerforationInfection and peritonitisFailure of enema reductionChronic intussusception - rare cause of failure to thrive

PRIORITIZATION OF NURSING PROBLEMSNursing Diagnosis:Acute Pain related to paroxysmal abdominal colicRisk for Ineffective Breathing Pattern related to abdominal distentionRisk for Decreased Fluid Volume related to vomitingAnxiety related to present hospitalizationKnowledge Deficit related to unfamiliarity to course of present illness

Nursing Care Plan

AssessmentNursing DiagnosisPlanningInterventionsRationaleEvaluationSubjective:I am experiencing on and off abdominal pain.Objective:Child cries intermittently (15- 30 minutes interval)LethargicFacial grimacePale in appearanceIrritableVital signs: Temp- 38 C PR- 126 bpm RR- 26/ minPain Related to paroxysmal abdominal colicRelief of pain after 2 hours of administration of analgesic while awaiting for the investigation report.Proper breathing technique demonstrated like breathing through mouth in perfect rhythm

Assessed the stability of the patient through monitoring vital signs.Inserted IV cannula and start IV fluid as ordered. Administered analgesic as ordered.Laboratory test and diagnostic procedure done. E.g CBC/ Abdomen UltrasoundBarium Enema done.

To improve respiratory difficulties.

To maintain proper hydration.To alleviate the abdominal pain.To arrive at probable diagnosis.Both for diagnostic and treatment modality.

After 2 hours of nursing intervention, client will be relieved from the abdominal pain as manifested by: Patient is more relax & comfortable.Vital signs:T- 37.2 CPR- 108 bpmRR- 21/ minNursing Health Teaching

Explain that recurrences are rare and usually occurs within 36 hours after reduction. Review signs and symptoms with parents.Review activity restrictions with parents (eg, positioning on back or side, quiet play, and avoidance of water sports until wound heals).Encourage follow up care.Provide anticipatory guidance for developmental age of child.

Conclusion

Intussusception is considered as one of the most common causes of bowel obstruction in infant and toddlers. In this case most patients may have deceiving healthy appearance, usually well nourished and generally above average in physical development. This fats and healthy appearance is apt to mislead us in the early hours of patients illness, we must not be reluctant as it may progress rapidly and makes child desperately ill. Any presence of unusual signs and symptoms must be reported immediately, so proper treatments and intervention may be given to prevent further complication.Early detection and immediate seek for medical assistance may lead to a better prognosis and for patients fast recovery.

Bibliography:Nelson Textbook of Pediatrics 19th Edition, by Kleigman, Stanton, St. Geme, Schor and Behrman.Lippincott Manual of Nursing Practice 9th Edition, by Lippincott, Williams and Wilkinswww.patient.co.uk Professional Referenceen.wikipedia.org/wiki/Intussusception_(medical_disorder)emedicine.medscape.com/article/930708-overview