TRIBHUWAN UNIVERSITY

INSTITUTE OF MEDICINE
NEPALGUNJ NURSING CAMPUS
BNS PROGRAMME

CASE STUDY
REPORT
ON

“STOMACH CANCER”

Submitted to; Submitted by;

Ms. Srijana Sapkota Niru Bhatta

Instructor BNS 3rd year

4th batch

2072/2073
ACKNOWLEDGMENT
I would like to thank God as finally I am able to finish this case study
report on Stomach cancer that has been prepared during my 2 weeks
clinical assignment in B.P Koirala Memorial Cancer
Hospitalfrom2073/10/18 to 2073/10/28.This report is prepared for the
fulfillment of Bachelor of Nursing Science Curriculum Third year. It was a
wonderful opportunity for me to study this case and to complete the case
study report on Stomach cancer.

I would like to express my gratitude and honor towards our Nursing

campus Nepalgunj and to respected Madam Ms. Kalpana Paudyal for
managing our duty at BPKMCH. A lot of thanks to my tutor, Ms. Srijana
Sapkota for all the support and guidance in helping me to finish my task
that really tested my abilities mentally and physically.

Special appreciation to the Hospital Director , Matron, ward Incharge and

nursing staff including other staff of hospital for providing me proper
orientation , Supervision, good cooperation and necessary information.

In addition, grateful acknowledgement to my patient keshav Bahadur

Karki and his family for their kind cooperation and providing me their
valuable information without those information case study would not be
successful.

Then, I would like thanks to my parents and friends, for supporting and
helping me finishing this report and during my whole study.

Thanks

ii
BACKGROUND

Gastric cancer mortality rates have remained relatively unchanged over the past 30
years, and gastric cancer continues to be one of the leading causes of cancer-related
death. Gastric cancer is rare before the age of 40, but its incidence steadily climbs
thereafter and peaks in the seventh decade of life.It is estimated that 876,340 cases of
primary gastric cancer were diagnosed in 2000, accounting for nearly 650,000
deaths worldwide.
Gastric cancer is the second most common cancer worldwide, with a frequency that
varies greatly across different geographic locations. It is a relatively infrequent
neoplasm in North America, yet contributes substantially to the burden of cancer
deaths. In North America, gastric cancer is the third most common gastrointestinal
malignancy after colorectal and pancreatic cancer, and the third most lethal neoplasm
overall.Despite the decreasing worldwide incidence, gastric cancer accounts for 3% to
10% of all cancer-related deaths.Although the survival rate for gastric cancer has
steadily improved in countries such as Japan, it has not in North America. The
substantial mortality associated with gastric cancer has prevailed despite technical
advances in surgery and the use of adjuvant therapy.
Ninety percent of all tumors of the stomach are malignant, and gastric adenocarcinoma
comprises 95% of the total number of malignancies. Curative therapy involves surgical
resection, most commonly a total or subtotal gastrectomy, with an accompanying
lymphadenectomy. The overall 5-year survival rate of patients with resectable gastric
cancer ranges from 10% to 30%.

iii
Table of Contents Page No.
OBJECTIVES.................................................................................................................................1
BIODEMOGAPHICAL DATA.......................................................................................................2
PHYSICAL EXAMINATION.........................................................................................................7
DEVELOPMENTAL TASK..........................................................................................................16
ANATOMY & PHYSIOLOGY OF GASTROINTESTINAL SYSTEM.......................................17
DISEASE PROFILE.....................................................................................................................23
Stomach cancer.........................................................................................................................23
Incidence...................................................................................................................................23
Risk factors...............................................................................................................................24
Types of gastric cancer..............................................................................................................24
Pathophysiology........................................................................................................................25
Staging of stomach cancer.........................................................................................................26
Clinical features........................................................................................................................28
Diagnostic Evaluation...............................................................................................................29
Management..............................................................................................................................31
DRUGS USED IN MY PATIENTS...............................................................................................32
PROGNOSIS................................................................................................................................38
COMPLICATION.........................................................................................................................38
NURSING MANAGEMENT.......................................................................................................39
NURSING CARE BASED ON OREM’S SELF-CARE DEFICIT THEORY..............................40
Application of self –care theory in my patient...........................................................................41
NURSING CARE PLAN..............................................................................................................44
DAILY PROGRESS NOTE..........................................................................................................49
STRESS MANAGEMENT...........................................................................................................50
DIVERSIONAL THERAPY AND ITS RESULT:.......................................................................50
HEALTH EDUCATION DURING HOSPITALIZATION..........................................................52
DISCHARGE TEACHING...........................................................................................................54
FOLLOW UP VISIT.....................................................................................................................56
WHAT I LEARNED FROM THE CASE STUDY.......................................................................56
SUMMARY..................................................................................................................................57
BIBLOGRAPHY..........................................................................................................................58

iv
v
OBJECTIVES
General Objective

The general objective of the case study is to provide holistic nursing care to the patient
by applying nursing process with the comprehensive knowledge of the client’s physical,
mental, social and spiritual status with the hospital stay.

Specific objectives

• To gain knowledge about one specific disease and its nursing management.

• To identify the causes of specific disease and its clinical feature in the patient.

• To take detail health history of the patient related disease.

• To collaborate with patient, family and health staffs for proper management of the
patient from admission to discharge.

• To perform general and systematic physical examination in logical sequence.

• To analyze the finding of patient’s general health and physical examination.

• To formulate appropriate nursing diagnosis and care plans on the basis of priority
of patients’ need.

• To provide holistic nursing care to patient according to nursing process.

• To explain the pathophysiology of patient’s disease condition and application of

this knowledge in planning nursing care.

• To explain and demonstrate sensitivity to the need of patient and assist them
toward own care as they improve.

• To alleviate pain, discomfort and stress, of patient by using nursing measures

• To analyze the finding of patient’s general health and physical examination.

1
• To formulate appropriate nursing diagnosis and care plans on the basis of priority
of patients’ need.

• To provide holistic nursing care to patient according to nursing process.

2
BIODEMOGAPHICAL DATA

Name Keshav Bahadur Karki

Age 60 years

Sex Male

Religion Hindu

Marital Status Married

Age group Elderly adulthood

Education 10th standard

Occupation Farmer

Hospital no 15731- 017

Bed no 97

Address Manarwa-9,Bara ,Narayani

Ward Ortho and Gastrointestinal Oncology Ward

Admission date 2073-10-10 at 2:30 pm

Date of interview 2073-10-19

Informants Patient himself &his wife, son

Attending doctor Dr. Ganga Sapkota

Provisional diagnosis Ca Stomach

Final diagnosis Ca Stomach with Gastric Outlet Obstruction

3
Chief Complaint:

Patient said that “I have pain in abdomin and loss of appetite since 1 month” .

History Of Present Illness:

Mr. Keshav Bahadur Karki was well before 1 month suddenly he had epigastric
pain , abdomin pain ,loss of appetite ,vomiting ,weight loss then he was treated at
Chitwan Medical College the symptoms didn’t relieve and he came to BPKMCH.
At BPKMCH on OPD necessary investigations were done and was admitted in
Ortho and gastrointestinal oncology(OGI) ward with provisional diagnosis of
Stomach Cancer and till then he is on continuous treatment.

Past medical history:

My patient had not undergone through the treatment of specific health problem
except fever and minor cut injuries.

Present surgical history

4
Gastrojejunostomy was done.

Operation note:

• Anesthesia : General anesthesia

• Position :Supine
• Peritoneum opened
• Omentectomy done
• Tumor was palpable at lower margin of abdomen(3.2cm)
• Gastrojejunostomy was done
• Wound closed

Past surgical history:

He has not done any type of surgery before.

Personal history

• Drinking and smoking habit : He has chronic drinking and smoking habit
• Dietary habit: Mixed habit
• No. of meal taken during a day: 3 times

5
• Meal timing:10am, 3pm, and 8pm
• Food Allergy: No any kind of food allergy
• Recreational Habit: He enjoy gardening, listening radio
• Fuel used in cooking: Gas and firewood
• Source of drinking water: Hand pump
• Type of toilet: Water sealed toilet
• Drainage system: Open
• Refuse disposal system: Dumping
• Elimination habit: Irregular bowel habit and normal bladder habit
• Rest and sleep habit:-6-7 hours sound sleep at night and 1-2 hours napping.
• Relationship: Harmonious relationship with family members and
neighborhood

Home environment

• House structure: Cemented house

• Composition of house: stones, bricks, aluminium and cement.
• Number of room: 3
• Kitchen: Separate

6
 Family medical history

All family members have good health, no history of communicable and non
communicable disease. According to my patient he has a family of total 6
members.

Name Ageee Educati Occupati Health Relationship

NRU o on Status with patient
n
Keshav SLC Farmer Ca stomach Patient
Bahadu
r Karki
Reema Devi 5 class Homemak Normal Wife
Khatri er
Subash Karki B.S.C Teacher Normal Son
Sharmila Karki 12 class Homemak Normal Daughter in
er law
Shushant karki 3 class Student Normal Grand son

Shila Karki L.K.G Student Normal Grand

Daughter

Socio economic condition

Economic status: middle class family

Family income: the main source of income is agriculture and teaching.

7
Psychological History:

He has no any psychiatric problem .He is very cooperative.

Health Seeking Behaviour:

He believe on both traditional healer and modern medicine but mostly he prefer
modern medicine.

8
Family Tree:
Father side y
Mother side

60 Inde Mal
yrs x e
Fem
ale
Pati
ent
Dea
d
fem
ale
Dea
d
male

9
PHYSICAL EXAMINATION

Assessing a patient’s health condition is a major component of nursing care so I

did a complete health assessment of my patient with starting from the head and
proceeding in systematic manner downward to toes to avoid omission. 

While doing physical examination, I applied all the methods of examination i.e.
inspection, palpation, percussion, and auscultation, smelling, clinical
measurement. The detailed findings are mentioned systematically below

80% information is gathered from history taking and 15% information from
physical examination and rest from diagnostic evaluation. So, physical
examination is vital tool to diagnose disease. It is done to collect objective data
which also reveals additional problems that the patient has not recognized before.

PHYSICAL EXAMINATION

10
 Date of Physical Examination Performed: 2073-10-19

Measurement:

Vital Signs:

• Blood pressure : 110/70 mm of hg

• Temperature : 98 degree Fahrenheit
• Pulse : 88/min
• Respiration : 24/min
• Height : 5 ft 7 inch
• Weight : 56 kg
• BMI :20kg/m2

General appearance:

Examination Findings

11
 Gait  Flexed forward
 General state of health  Fear ,anxious and weak appearance
 Nutritional status  satisfactory
 Behavior  co-operative
 Cleanliness  well groomed and well dressed
 Orientation  Oriented to time ,place and person

Skin:

Examination Findings

 color uniform all over the body

 Skin free of lesion and abrasions
 Wrinkles present on face.
 No edema
 No sweating or sign of dehydration
 Dry hair , black hair in color uniform
distribution
 Clean skin

 No visible bleeding

Palpation
 Warm skin, even temperature
 Temperature
 Elastic skin: skin comes back to previous state
 Dehydration quickly

 Smooth skin
 Texture

12
Lymph Nodes:

Examination Findings

Inspection
 Redness or  Cervical axillary ,groin lymph nodes not
enlargement of lymph nodes visible, no redness

Palpation
 Enlargement  Lymph nodes not palpable
 Tenderness  No tenderness

Head and face:

Examination Findings

Inspection
 Shape and size  Round oval face
 Swelling, injury or infection  No swelling, injury or
on head infection
 Face for movement of  Uniform movements of both
two sides sides of face
 Hair loss  No hair loss

Palpation
 Swelling, tenderness and  No swelling, tenderness, and
depression. Depression

Percussion

 To sinuses for tenderness  No tenderness over maxillary

and frontal sinuses

13
Eye :

Examination Findings

Inspection
 Eye for bulges  No bulges
 Eyelids  No swelling, redness, drooping
 Palpebral  Pink in color, no discharge, foreign
conjunctiva. body, dryness or tear flowing.

 Pink in color
 Transparent, no abrasions, or white
spots
 Bulbar conjunctiva
 White in color with few small blood
 Cornea
vessels

 Sclera

 Round and uniform in size and

 Pupils shape , when light approaches
pupils constrict in both eyes.
 Normal.
 Visual acquity test;
 Snellen’s chart 14 inch far from
 Accommodation
patient
 Six position of cardinal gaze for
extraoccular muscle movement
 Confirmation test ; 2 ft infront of
patient
 Conversion test
 All test are normal

Ear:

Examination Findings

Inspection
 External ear for location  Top of pinna meets the
eye- occupit line.
 Pinna for any lump or  No lump, lesion, smooth
lesion rounded

14
 External auditory canal for  No redness, discharge ,mass or
any : foreign body with minimal
redness discharge, mass, cerumen
foreign body, or cerumen.
 Mastoid area for redness  No redness or swelling.
or
Swelling

Palpation
 Pinna  No tenderness
 Skin flap  No tenderness
 Mastoid area  No tenderness
 Hearing test  Whispering : patient is able to reply the word i
whisper in his ear
 Tuning fork test;
 Weber test : Normal
 Rinne test :Normal

Nose:

Examination Findings

Inspection
 Nose for location  Centrally located
 Nostrils  Nostrils are uniform in size and do
not flare.
 No polyp or deviation
 Dark pink in color, no discharge or
 Nasal septum foreign body.
 Nasal canals  Normal smelling capacity

 Smelling

Mouth and Throat:

Examination Findings
15
Inspection

 Lips  Pink in color moderately dry, no cracks

and ulcers
 Mucous membrane  No ulcers are present.
 Gums  Pink no swelling, no redness or bleeding
 Teeth  White with black lines, missing teeth and
dental carries present

 Symmetrical, pink ,moist, midline

 Tongue fissure present.
 No Swallowing difficulty
 Throat/tonsils  Pink small tonsils
 No difficulty
 Swallowing difficulty

Palpation
 No swelling, tenderness
 Gums  No tooth ache, no loose tooth
 Teeth

Smell  No foul odour, or smell of alcohol or smoke.

Neck:

Examination Findings

Inspection

 The neck position  tilting of head

 For enlargement of thyroid  No enlargement

16
gland  full range of motion
 Ability to move neck
 Back of neck for lump or  No swelling or lump
Tenderness
 Neck vein distensions  No distended neck vein

Palpation

 Back of neck for tenderness  No tenderness

 Thyroid gland for  Thyroid not palpable and non
tenderness Tender

Chest and lungs:

Inspection

 The shape and size  Lateral diameter more than anterior

posterior diameter

 Symmetry  Symmetrical shape, sternum is

centrally located

 Expansion during breathing  Even expansion of chest

 Intercostals spaces  No intercostals retraction
 Cough  No cough

Palpation

 Chest wall(9-10 area) for  No tenderness, mass lumps or

tenderness, mass depression
lumps, or depression
 Even expansion of the chest on
 The chest for expansion both sides

 Chest fremitus  Normal, equally felt on both

side of chest
 For tenderness in vertebral
 No tenderness
column
 Normal, thumbs meet and depart
 Posterior chest excursion
on inhalation and exhalation.

17
 Percussion

 The front and back of of the  Hyper resonant sounds over the lungs.
chest.

Auscultation  Normal bronchial ,vesicular ,broncho-

vesicular sound in all area of chest.
 The front and back of chest.  Inspiration is longer than
 Compare inspiration and expiration ,no crepts or wheezes
expiration.

Heart :

Examination Findings

Inspection

 Neck veins  No distended neck veins.

 Clubbing of nail  No clubbing of nail
 Cyanosis  No cyanosis

Palpation

 Heart to determine the size  Heart normal in size apex beat

palpable at 5th intercostals.

Percussion

 Heart  Dull sound over heart from 2nd

18
 to 5th intercostals.

Auscultation

 Areterio –ventricular valve  Lub sound present

 Aortic -pulmonary  Dub sound present

Breast:

Examination Findings

Inspection

 Both breast and nipple for  Breast and nipple are uniform in size
size, uniformity, colour. and shape, nipple point to same direction.
 Any swelling.  No swelling

Palpation

 Breast to check for mass ,  No mass, swelling or tenderness

swelling or tenderness present.

Abdomen:

Examination Findings

Inspection

 Shape, size, scars, swelling,  Flat shaped, uniform shape, scar present
and distended blood vessels of surgical incision
no visible blood vessels.

Auscultation

 Bowel sounds  Bowel sounds are not present in all

quadrants .

19
 Percussion

 In all areas  Tympany over stomach and intestines

whereas dull over liver, spleen and kidneys
 Non tender kidneys.

 Kidneys for tenderness

Palpation

 All areas of abdomen  no abdominal mass

 Tenderness and pain over abdomen due
to surgical procedure,
 Liver  not palpable
 Spleen  not palpable
 Kidneys  not palpable

Anus:

No any irritation, crack, fissure or enlarged vessels reported.

Genitalia:

No redness, swelling reported.

Arms and legs:

Examination Findings

Inspection

 arms and legs for symmetry,  Symmetrical in size and shape, no

edema or lesions. edema, no lesions

20
Palpation

 Arms and legs for edema  No edema.

Musculo skeletal system:

Examination Findings

Inspection

 Muscles and joints  No bone or joint deformity, no redness

or swelling of joints ,no muscle wasting.
 Joint movements
 Spine is midline slightly curved out
 Patient’s spine from neck and gradually curving inward at the
waist.

Palpation

 Patient’s neck, shoulder,  No tenderness.

elbows, knees ankle joints for
swelling, tenderness and
temperature.
 Note any rough sensation at
joints during range of motion.
 Full range of motion and smooth joint
movement in both side of body.

21
Nervous system:

Examination Findings

 Muscle strength  equal strength in both hands and

feet

 Sensation  Feels good sensation on both

side of the body.

 Coordination  Co-ordinated movements in both

side of body.

 Reflexes  Planter, patellar, biceps, triceps,

radial reflexes present and are present
and normal on both side .

Abnormal Findings of Physical Examination:

 Overall assessment of physical examination is normal is normal.

 Patient feels lethargic

 Pain in incisional site

 Bowel sound absent

DEVELOPMENTAL TASK

A developmental task is a task which arises at or about a certain period in the life
of an individual , successful achievement of which leads to his happiness and to
success with later tasks while failure leads to Unhappiness in the individual
,disapproval by society and difficulty with later tasks .

22
My patient belongs to elderly adulthood which starts at 60 and extends to death ,
while physical and phychological decline speed up at this time .Development
tasks of elderly adult (Harighurst’s)

Patient picture
Book picture

1.Adjusting to decreasing physical strength & • Achieved

health

2.Adjusting to retirement & reduce income. • Achieved

3.Adjusting to death of the spouse. • Not achieved

4.Establishing an explicit affiliation with one’s • Achieved

age group.

23
ANATOMY & PHYSIOLOGY OF GASTROINTESTINAL SYSTEM

Organ of Gastrointestinal system

• Mouth
• Pharynx
• Esophagus
• Stomach
• Small intestine
• Large intestine

Accessory organ
• Three pairs of salivary gland
• Pancreas
• Liver
• Gall bladder and bile ducts

Stomach

The stomach is the first intra-abdominal part of the gastrointestinal (GI), or

digestive, tract. It is a muscular, highly vascular bag-shaped organ that is
distensible and may take varying shapes, depending on the build and posture of

24
 the person and the state of fullness of the organ . The stomach lies in the left upper
quadrant of the abdomen.

Location – epigastrium, umbilical, left hypochondrium under cover of the ribs

Shape - “J” when empty

Length = 25 cm

Capacity - 2 litres in adults

layers

The stomach walls consist of an outer mucosa, and inner submucosa, muscularis

externa, and serosa.

External features

 2 orifices (openings)

1. cardiac

2. pyloric

 2 curvatures (borders)

1. Greater (left) - convex

2. Lesser (right) – concave

 2 surfaces

1. Anterior

2. Posterior

25
  2 Parts

1. Cardiac - Fundus (dome), Body

2. Pylorus (10 cm) – pyloric antrum (7.5 cm), pyloric canal (2.5cm)

Internal features

 Gastric rugae – mucosal folds

 Gastric pits – mucosal depressions, contain openings of gastric glands

 Gastric canal (magenstrasse) – longitudinal rugae along the lesser curvature

Functions

• Digestion
Gastric juice in the stomach also contains pepsinogen. Hydrochloric acid
activates this inactive form of enzyme into the active form, pepsin. Pepsin breaks
down proteins into polypeptides.

• Absorption

Although the absorption is mainly a function of the small intestine, some absorption of
certain small molecules nevertheless does occur in the stomach through its lining. This
includes:

Water, if the body is dehydrated

Medication, like aspirin
Amino acid
10–20% of ingested ethanol (e.g. from alcoholic beverages)
Caffeine
To a small extent water-soluble vitamins (most are absorbed in the small intestine)
The parietal cells of the stomach are responsible for producing intrinsic factor, which is
necessary for the absorption of vitamin B12 is used in cellular metabolism and is
necessary for the production of red blood cells, and the functioning of the nervous system.
26
 • Control of secretion and motility

The movement and the flow of chemicals into the stomach are controlled by both
the autonomic nervous system and by the various digestive system hormones:

The hormone gastrin causes an increase in the secretion of HCl

from the parietal cells, and pepsinogen from chief cells in the
stomach. It also causes increased motility in the stomach. Gastrin
Gastrin is released by G cells in the stomach in response to distension of
the antrum, and digestive products (especially large quantities of
incompletely digested proteins). It is inhibited by a pH normally
less than 4 (high acid), as well as the hormone somatostatin.

Cholecystokinin (CCK) has most effect on the gall bladder,

causing gall bladder contractions, but it also decreases gastric
Cholecystokinin emptying and increases release of pancreatic juice which is
alkaline and neutralizes the chyme. CCK is synthesized by I-cells
in the mucosal epithelium of the small intestine.

In a different and rare manner, secretin, produced in the small

Secretin intestine, has most effects on the pancreas, but will also diminish
acid secretion in the stomach.

Gastric inhibitory Gastric inhibitory peptide (GIP) decreases both gastric acid release
peptide and motility.

Enteroglucagon Enteroglucagon decreases both gastric acid and motility.

27
 • Stomach acid

Epidermal growth factor (EGF) results in cellular proliferation, differentiation, and

survival. EGF is a low-molecular-weight polypeptide first purified from the mouse
submandibular gland, but since then found in many human tissues including
submandibular gland, parotid gland. Salivary EGF, which seems also regulated by dietary
inorganic iodine, plays also an important physiological role in the maintenance of oro-
oesophageal and gastric tissue integrity. The biological effects of salivary EGF include
healing of oral and gastroesophageal ulcers, inhibition of gastric acid secretion,
stimulation of DNA synthesis as well as mucosal protection from intraluminal injurious
factors such as gastric acid, bile acids, pepsin, and trypsin and to physical, chemical and
bacterial agents.

• Stomach as nutrition sensor

The stomach can "taste" sodium glutamate using glutamate receptors  and this information
is passed to the lateral hypothalamus and limbic system in the brain as
a palatability signal through the vagus nerveThe stomach can also sense, independently to
tongue and oral taste receptors, glucose , carbohydrates,proteins , and fats.This allows the
brain to link nutritional value of foods to their tastes.

Blood supply

• Gastric arteries
• Splenic artery

Nerve supply

• Sympathetic – T6 - T10 segments of spinal cord

• Parasympathetic – 2 vagus nerves.

Clinical anatomy

28
 Gastric pain is felt in the epigastrium.

 Interior of stomach can be viewed by gastroscopy or barium meal x-ray.

 Gastric ulcers are common in lesser curvature.

 Gastric carcinoma is common in greator curvature.

 Pyloric obstruction is seen as visible peristalsis.

Small intestine

Small intestine or small bowel is the part of the GI tract between the stomach and
the large intestine and is where most of the end absorption of food takes place

.Extent - from the pylorus to ileocaecal junction.

Length = 3m -5m

Parts
The small intestine is divided into three structural parts.

1. The duodenum

It  is a short structure (about 20–25 cm long) continuous with the stomach and
shaped like a "C".It surrounds the head of the pancreas. It receives
gastric chyme from the stomach, together with digestive juices from
the pancreas (digestive enzymes) and the liver (bile).
The duodenum contains Brunner’s gland, which produce a mucus-rich alkaline
secretion containing bicarbonate. These secretions, in combination with
bicarbonate from the pancreas, neutralize the stomach acids contained in gastric
chyme.

2. The jejunum

29
 It  is the midsection of the small intestine, connecting the duodenum to the ileum.
It is about 2.5 m long, and contains the plicae circularis, and villi that increase its
surface area. Products of digestion (sugars, amino acids, and fatty acids) are
absorbed into the bloodstream here. The suspensory muscles of duodenum marks
the division between the duodenum and the jejunum.

3. The illeum:

The final section of the small intestine. It is about 3 m long, and

contains villi similar to the jejunum. It absorbs mainly vitamin B 12 and bile acid,
as well as any other remaining nutrients. The ileum joins to the caceum of the large
intestine at the illeocecal junction.

Function

• The primary function of the small intestine is the absorption of nutrients and
mineral from food
• Digestion
• Immunological

Blood supply[
The small intestine receives a blood supply from the ceoliac trunk and the superior mesenteric
artery

30
 DISEASE PROFILE
Stomach cancer

• Cancer of the stomach, or gastric cancer, is a disease in which stomach cells

become malignant (cancerous) and grow out of control, forming a tumor.
• Almost all stomach cancers (95%) start in the glandular tissue that lines the
stomach.

31
 • The tumor may spread along the stomach wall or may grow directly through
the wall and shed cells into the bloodstream or lymphatic system
• Stomach cancers are classified according to the type of tissue in which they
originate.
• Adenocarcinomas -- the most common -- start in the glandular stomach lining.
• Lymphomas develop from lymphocytes, a type of blood cell involved in the
immune system.
• Sarcomas involve the connective tissue (muscle, fat, or blood vessels).

Incidence

• The American Cancer Society’s estimates for stomach cancer in the united
states for 2017 are:
• About 28,000 cases of stomach cancer will be diagnosed (17,750 in men and
10,250 in women)
• About 10,960 people will die from this type of cancer
• Stomach cancer mostly affects older people.
• About 6 of every 10 people diagnosed with stomach cancer each year are 65 or
older.
• The average risk that a person will develop stomach cancer in their lifetime is
about 1 in 111.
• Stomach cancer is much more common in less developed countries.

In BPKMCH , from 2073/4/1 to 2073/10/27

Patient admitted on Gastrointestinal oncology Ward diagnosed with Ca Stomach:

 Total cases :48

• Male cases:31
• Female case :17

Risk factors

32
 Book picture Patient picture

Unknown

Gender ;Male have double risk then Male patient

Female

Race ;African American or Asian Asian race

Genetics Not significant

Blood type : Blood group A is at risk +ve

AB

Advanced age 60 years

Family history Not significant

Patient picture Book picture

Lifestyle; smoking, drinking alcohol, Cigarette smoking since 20 years ago

high in salted, smoked, or nitrate- 1packet/day and alcohol intake daily from
preserved foods last 10 years

Helicobacter pylori (H. pylori) infection Not significant

Chronic gastritis, pernicious anemia, Chronic gastritis

gastric polyps and prior stomach surgery.

Work-related exposure due to coal Not significant

mining, nickel refining, and rubber and
timber processing and asbestos exposure

Types of gastric cancer

1. Adenocarcinoma

33
About 90% to 95% of cancers of the stomach are adenocarcinomas. When the
term stomach cancer or gastric cancer is used, it almost always refers to an
adenocarcinoma.

These cancers develop from the cells that form the innermost lining of the
stomach (known as the mucosa).

2. Lymphoma

.These are cancers of the immune system tissue that are sometimes found in the
wall of the stomach. About 4% of stomach cancers are lymphomas. The treatment
and outlook depend on the type of lymphoma.

3. Gastrointestinal stromal tumor (GIST)

These are rare tumors that start in very early forms of cells in the wall of the
stomach called interstitial cells of Cajal. Some of these tumors are non-cancerous
(benign); others are cancerous. Although GISTs can be found anywhere in the
digestive tract, most are found in the stomach.

4. Carcinoid tumor

These are tumors that start in hormone-making cells of the stomach. Most of these
tumors do not spread to other organs. About 3% of stomach cancers are carcinoid
tumors.

5 .Other cancers: Other types of cancer, such as squamous cell carcinoma, small
cell carcinoma, and leiomyosarcoma can also start in the stomach, but these
cancers are very rare.

34
 In my patient

• Adenocarcinoma type of stomach cancer was seen.

Pathophysiology

• Most gastric cancers are adenocarcinomas.

• The tumor infiltrates the surrounding mucosa, penetrating the wall of the stomach
and adjacent organs and structures
• Liver, pancreas, esophagus and duodenum are often affected at the time of
diagnosis

Staging of stomach cancer

The TNM system for staging contains 3 keys

T categories of stomach cancer

•Tx : The main tumor cannot be assessed

•To:No sign of a main tumor can be found

35
•Tis :Cancer cells are only in the top layer of cells of the mucosa(innermost layer of
the stomach) and have not grown into deeper layers of tissue such as lamina
propria or muscularis mucosa.This stage is also known as carcinoma in situ

•T1 : The tumor has grown from the top layer of cell of the mucosa into the next
layers below the submucosa.
•T1a :The tumor is growing into the lamina propria or muscularis mucosa.
•T1b :Tthe tumor has grown through the lamina propria and muscularis mucosa and
into the submucosa

•T2 :The tumor is growing into the muscularis propria layer

•T3:The tumor is growing into the subserosa layer

•T4 :The tumor has grown into the serosa and may be growing into a nearby organ
(spleen ,intestine ,pancreas ,kidney e.t.c) or other structure as major blood vessels.
•T4a :The tumor has grown through the stomach wall into the serosa ,but the cancer
hasn’t grown into any of the nearby organs or structures.
•T4b: The tumor has grown through the stomach wall and into nearby organs or
structures.

N categories of stomach cancer

•Nx :Nearby lymph nodes cannot be assessed

•No :No spread to nearby lymph nodes

36
•N1 :The cancer has spread to 1-2 nearby lymph nodes

•N2 :The cancer has spread to 3-6 nearby lymph nodes

•N3 :The cancer has spread 7 or nearby lymphnodes

•N3a :The cancer has spread to 7 -15 nearby lymph nodes

N3b :The cancer has spread to 16 or more nearby lymph nodes

M categories of stomach

•Mo :No distant metastasis

•M1:Distantmetastas

37
Clinical features

Book picture Patient picture

Asymptomatic in early stage

Indigestion and stomach discomfort Stomach discomfort

Mild nausea Nausea

Loss of appetite Loss of appetite

Heartburn Heartburn

A bloated feeling after eating Bloating of stomach

In more advanced stage

Discomfort in the upper or middle part of Discomfort in middle abdomen

the abdomen

Blood in the stool (which appears as Normal stool color

black, tarry stools)

Vomiting or vomiting blood Vomiting only

Weight loss 4 kg less body weight

Weakness or fatigue associated with mild Not significant

anemia (a deficiency in red blood cells)

Palpable nodules around the umbilicus, Not significant

called Sister Mary Joseph’s nodule is
usually palpable

38
Diagnostic Evaluation

According to book In my patient

History Taking History Taking

Physical Examination Physical Examination

Blood tests Blood tests

Chest X-ray Chest X-ray

Oesophagus Gastro Duodenoscopy ?Ca Stomach

Biopsy Moderately differentiated tubular

adenocarcinoma of stomach

Book picture Patient picture

CT Scan Irregular thickening of the posterior

wall of the antrum and pylorus of the
stomach ? malignancy

MRI Not done

PET Scan Not done

39
Blood chemistry

Investigations Findings Unit Ref. range

Hemoglobin 13.4 gm/dl M-13-17

F- 12-15

Platelet count 149000 /mm3 150,000- 400,000

WBC 11100 /mm3 4,000-10,000

Neutrophil 85 % 40-80

Lymphocyte 10 % 20-40

Eosinophil 02 % 01-06

40
 Monocyte 03 % 02-10

Glucose random 98 Mg/dl 50-130

Urea 31 mg/dl 15- 40

Creatinine 1.09 mg/dl M-0.6-1.3

F-0.6-1.0

Sodium 136 mmol/l 136-145

Potassium 4.8 mmol/l 3.5-5.1

Uric acid 5.0 mg/dl M -3.5-7.2

F -2.6-6.0

PCV 50.6 % 36-54

Investigations Finding Unit Ref . Range

Bilirubin Total 0.47 mg/dl 0.2-1.0

Bilirubin Direct 0.04 mg/dl 0.0-0.2

SGOT/AST 27 U/L 15-37

SGPT/AST 46 U/L 14-63

Alkaline phosphate 77 U/L 46-116

(ALP)

Lactate 146 U/L 81-234

dehydrogenase(LDH)

41
Management

Book picture Patient picture

Surgery Surgery(Gastric bypass)

Chemotherapy Not given

Radiation Not given

Combination of radiation and Not given

chemotherapy

Surgery

• Endoscopic resection: Endoscopic mucosal resection and endoscopic submucosal

resection can be used only to treat some very early-stage cancers, where the
chance of spread to the lymph nodes is very low.
• Subtotal (partial) gastrectomy: Only part of the stomach is removed, sometimes
along with part of the esophagus or the first part of the small intestine (the
duodenum). The remaining section of stomach is then reattached.
• Total gastrectomy: This operation is done if the cancer has spread throughout the
stomach. The surgeon removes the entire stomach, nearby lymph nodes, and
omentum, and may remove the spleen and parts of the esophagus, intestines,
pancreas, or other nearby organs.
• Gastric bypass (gastrojejunostomy): A gastrojejunostomy is a surgical
procedure that directly connects the stomach to the jejunum.
• Endoscopic tumor ablation: In some cases, such as in people who are not
healthy enough for surgery, an endoscope can be used to guide a laser beam to
vaporize parts of the tumor. This can be done to stop bleeding or help relieve a
blockage without surgery.
• Stent placement: Another option to keep a tumor from blocking the opening at
the beginning or end of the stomach is to use an endoscope to place a stent keep in
the opening.
42
• Feeding tube placement

DRUGS USED IN MY PATIENTS

• Inj Ritezone –T 1.125gm I/V BD

• Inj ketrol 30 mg I/V TDS
• Inj Metris 500mg I/VTDS
• Inj Ondem 8 mg I/V SOS
• Inj Pantocid 40 mg I/V BD
• Inj Hybro 20 mg I/V TDS
• Inj lasix 10 mg I/V SOS

43
INJ RITEZONE

MOA INDICATION CONTRAINDICATION SIDE EFFCTS NURSING

CONSIDERATION

It inhibits cell Gram positive Hypersentivity to G.I: pseudomembranous Ask when dissolve the solute
wall synthesis, infection resistant to cephalosporin, use colitis, diarrhea by shaking the vial well.
promoting penicillin cautiously in patients with Reconstituted solution is
osmotic impaired renal function Hematologic:
stable for 24hr at room
instability;  UTI by gram and penicillin allergies eosinophilia,
temperature under
usually negative and in breastfeeding thrombocytosis,
refigeration, thereafter it
bactericidal in organism women. leukopenia.
should be discarded.
action.  Septicemia
Skin: pain, induction, For I/v injection, the solution
 Surgical
tenderness at injection should be adequately diluted.
prophylaxis
site, rash. Don’t inject more than 1gm
 Typhoid into single IM site to prevent
 Meningitis Other: hypersensitivity pain and tissue reaction.
 Actue bacterial reactions,serum
Don’t mix Aminoglycosides
otitis media sickness, anaphylaxis.
or sodium bicarbonate with
cephalosporin

44
INJ. METRONIDAZOLE

MOA INDICATIONS CONTRAINDI SIDE EFFECTS NURSING CONSIDERATION

CATIONS
Take up by cells Anaerobic CNS: Headache, dizziness,  Question for history of
in susceptible confusion, irritability, ataxia, hypersensitivity to Metronidazole.
infections Hypersensitivity
micro organism. depression, fatigue, drowsiness,  Determine pattern of bowel activity.
to Metronidazole
Disrupts, DNA endocarditis, insomnia.  Monitor intake and output and assess
or other
synthesis, inhibits CV: Flattening of T wave for urinary problems.
septicemia, Nitroimidazoled
nucleic acid ENT: Blurred vision, sore  Be alert to neurological symptoms:
erivative
synthesis amebiosis, throat, dry mouth, metallic test, dizziness, numbness, tingling or
pregnancy 1st
producing furry tongue, , photophobia. paresthesia of extremities.
duodenal ulcer, trimester,
bactericidal, GI: Nausea, vomiting,  Assess for rash, urticaria.
renal/hepatic/GI
amebicidal, decubitus ulcer diarrhea, abdominal cramps.  Watch for onset of super infection:
diseases,
trichomonacidal GU: Darkened urine, vaginal ulceration or changes of oral mucosa,
inflammatory contracted visual
effects- produce- dryness, polyuria, dysuria, furry tongue, discharge, genital/ anal
or color fields,
anti-inflammatory bowel disease cystitis, dreased libido, pruritus.
blood dyscrasias,
effects. Produces neurotoxicity,incontinence,
CNS disorders.  Assess vision after therapy.
immune dyspareunia, candiasis.
 Maintain intake and output, wt
suppressive HEMA: Leucopenia,
daily,stool for number , frequency and
effects when bonemarrow depression, aplasia.
color.
applied topically. INTEG: Rash, pruritis,
urticaria, flushing.

45
INJ. PANTOPRAZOLE
MOA INDICATIONS CONTRAINDICATIONS SIDE EFFECTS NURSING
CONSIDERATIONS
is a Proton pump peptic ulcer, Pregnancy Nausea - -Do not crush tablets.
inhibitor of the reflux liver disease Vomiting
breast feeding. abdominal pain - -Toxicity may cause
apical membrane esophagitis,
of the parietal cell, ZollingerEllision flatulence confusion,drowsiness,blurred
thereby inhibition syndrome, diarrhea
headache vision.
of gastric acid NSAID induced
dry mouth insomnia- -Explains importance of taking
production gastritis.
,drowsiness ,rash ,pruritus.
drugs exactly as prescribed.
- -Tell patients to take medicines
before meal.

46
MOA INDICATIONS CONTRAINDICA SIDE EFFECTS NURSING CONSIDERATION
TIONS
It is a 5-HT3 - Drug induced nausea -Lactation, -Dryness of mouth, -It should be given deep IM prevent
antagonist,which and vomiting. -children upto 2 blurred vision, tissue irritation.
block the -Post-operative nausea years of age. -Dizziness, sedation, -Instruct the patient that medicine may
depolarizing and vomiting. headache, produces drowsiness and supervise on
action of %Ht -Nausea vomiting . -In-coordination, ambulation.
through %-Ht fatigue, euphoria, -Extra pyramidal reaction may appear
receptors on the tremor, early in the drug therapy so should
vagal efferents in -GI upset, drug fever, observed the symptoms carefully and
the GI tract and in skin rashes to informed the doctor.
the brain to sensitization,- -Extra -Donot mix with other drugs except
decrease pyramidal reaction, pethidine.
sensitivity of -Rarely blood disorder. -Advised patient to report twitching or
nausea & involuntary movement
vomiting.

INJ ONDANSTERON

47
INJ LASIX

MOA INDICATION CONTRAINDICATION SIDE NURSING CONSIDERATION

EFFECTS

Fursemide is a Oedema Hypotension  Increased  Monitor weight, blood pressure and pulse
powerful diuretic. It Hypertension Hearing problems urination rate routinely with long term use.
interferes with salt Lasix may be  Dehydrat  Drug is potent diuretic and can cause severe
(sodium, chloride) and used alone, or ion diuresis with water and electrolyte
water absorption in the in conjunction  Low depletion. Monitor patient closely.
blood pressure
kidney, and increases with other  If oliguria or azotemia develops or increaese,
 Muscular
the amount of water agents. cramps drug may need to be stopped.
lost from the body in  An  Monitor fluid intake and output and
the urine.The onset of increase in the electrolyte, BUN and carbodioxide level
action is less than one level of blood frequently.
hour after oral dosing, sugar  Watch for the signs of hypokalemia,such as
and less than five  Possible muscle weakness and cramps.
minutes after gout  Monitor glucose in diabetic patients.
 A
intravenous  Watch for sign of joint swelling, tenderness
ringing in the
administration. ears or pain, as these may indicate onset of gout;
Frusemide has a half  Enlarge discontinue drug and notify physician if any
life of 100 minutes. ment of breasts sign present.
in men or  Administer drug in the morning and early
changes in
sexual desire. afternoon to avoid nocturia and interruption.

48
49
PROGNOSIS

Generally poor prognosis; the diagnosis is usually made late because most patients are
asymptomatic during early stage of disease.

COMPLICATION

Book picture Patient picture

Abdominal pain Abdominal pain
Dysphagia Not significant
Hepatomegaly Not significant
Haemolytic anaemia Not significant
Sister Mary Joseph’s nodule Not significant
Gastric ulcer Gastric ulcer
Bowel obstruction Not significant

Esophageal stricture Not significant

Pyloric stenosis Gastric outlet obstruction

50
NURSING MANAGEMENT
General nursing management applied to my patient with diagnosis of Stomach cancer:

 Assess the general condition of patient, pain, sign of infection (fever, flushed face), ,
nutritional status (weight, BMI) and lab studies.
 Position the patient for comfort.
 Manipulate the environment, as necessary to increase comfort and to minimize
unnecessary exertion.
 Consider implementing complementary and alternative medicine intervention for pain
control as well as for management of nausea, vomiting and anxiety. ( music therapy,
relaxation technique etc
 Record vital sign 4 hourly
 Instruct to perform oral hygiene every day.
 Provide adequate nutrition through small frequent meals, soft non irritating food, provide
nutritional supplements as well as maintain intake and output to monitor fluid status.
 Position patient in mid or high fowlers position
 Encourage patient to turn and breathe deep at least q2h(or more frequently until
ambulating well)
 Splint or support incision with hands or folded towel during coughing if needed to clear
secretion
 Encourage ambulation
 Record daily body weight.
 Provide for periods of rest alternating with ambulation.
 Involve patient in self-care activities that may increase their independence.
 Provide emotional support and discuss the impact of uncertain future and allow the patient
to ventilate his feeling, doubts and concerns.
 Encourage patient to involve in self-care activities. Be available to the patients and
visitors when they want to discuss their feelings.
 Offer kindness, concerns, consideration and sincerity towards child and parents.
 Offer hope that therapy will be effective and will prolong life.

51
 NURSING CARE BASED ON OREM’S SELF-CARE DEFICIT THEORY
• Dorothea E. Orem was born on 1914, in Baltimore, Maryland. The self-care deficit
nursing theory that was developed between 1959 and 2001. It is also known as the
Orem Model of Nursing.

• According to Orem ,“ Nursing has it’s special concern; the individual need for self
care action and the provision and management of it on a continuous basis in order to
sustain life and health, recover from disease or injury and cope with their effects”.
• Orem’s approach to the nursing process presents a method to determine the self-care
deficit and then to define the roles of the person or the nurse to meet the self-care
demands of an individual. The step of Orem’s nursing process may be summarized as
follows:

Orem developed her general theory of nursing in 3 related parts which are:

1. Theory of Self care

2. Theory of Self care deficit
3. Theory of nursing system
1.Theory of self care:
• Self care agency
• Therapeutic self care demand
• Self care requisites-
2.Theory of self care deficit: when nursing care is needed

3.Theory of nursing system

• It postulates that a nursing system forms when nurses prescribe, design and provide
nursing that regulates the individual’s self-care capabilities and meets therapeutic self
care requirements.
• Orem has identified three classifications of nursing system:
I. Wholly compensatory system
II. Partially compensatory system
III. Supportive educative system

52
 My patient Mr keshav karki with diagnosis ca stomach can perform activities of daily
living but he needs assistance so I applied partly compensatory nursing system of
Orem’s model. The following are the steps of application of this model:

 Partially compensatory system

 The partly compensatory nursing system is represented by a situation in which both
nurse and patient perform care measures or other action involving manipulative tasks
or ambulation , either the patient or nurse may have the major role in the performance
of care measure

Application of self –care theory in my patient

1. Assessment
Basic condition factor
Age 60 years

Gender Male
Health state Ill health
Development state Integrity versus despair
Socio cultural orientation He is educated and belongs to hindu culture.
Health care system Institutional health care
Family system Married
Patterns of living Living in home with partner and children
and grandchildren
Environment He used to live in rular area
Resources (source of income) Self and Son

53
Universal Self Care Requisites
Air Breaths out normally, no pallor cyanosis
Water Fluid intake is sufficient. Turgor normal for the
age.Edema not present over ankles.
Food Food intake is not adequate due to surgical
procedure gastrojejustonomy.
Elimination Normal bowel and bladder habit.
Activity /rest Activity level has come down temporarily
because of surgery. Patient is on rest due to
pain and surgery

Social interaction Good relation with family members and

hospital staffs.
Prevention from hazards Support the patient during walking , minimize
the risk of infection.
Promotion of normal He has good relation with family members.
functioning

Developmental Self-Care Requisites

Maintainance of development Able to feed self , Difficult to walk due to
environment surgery.

Prevention/ management of the Discuss the problem with family members

conditions threatening the normal and hospital staffs.
development

Health Deviation Self Care Requisites

Reports the problems to the doctor when in the
Adherence to medical regimen hospital. Cooperates with the medication, Not
much aware about the use and side effects of

54
 medicines

Awareness of potential problem Not aware about the actual disease process  
associated with the regimen Not compliant with the diet and prevention of
hazards. Not aware about the side effects of the
medications and complications.
Modification of self image to Has adapted to limitation in activity , dietary
incorporates changes in health status change.

Adjustment of lifestyle to Adjusted with the his disease process but pain
accommodate changes in health status tolerance not achieved.
and medical regimen

2.Nursing Diagnosis
Therapeutic self-care demand: - deficit area; food, activity and rest, prevention of
infection and bleeding, knowledge of disease process.

Adequacy of self-care agency: - inadequate

Identified problems Nursing diagnosis

Pain in operative site • Pain in incision site related to surgery.
Low nutritional status • Imbalanced nutrition less than body requirements
related to anorexia as evidenced by weight loss.
Fear and anxiety related to diagnosis • Anxiety related diagnosis of cancer as
and uncertain prognosis evidenced verbalization of fear of death.
Immobility and risk of infection • Risk of chest infection related to ineffective
airway clearance secondary to post operative
procedure
Increase risk due to abdominal • Risk of infection related to invasive procedures.
drain ,catherization , I/V line, NG
insertion .

55
 NURSING CARE PLAN
SN Assessment Nsg diagnosis Nsg goal - Planning Intervention Rationale Evaluation
2073/ Subjective data: “I Pain in Short - Assess the - Assist - Useful in Pain has been
10/18 have severe pain incision site tem characteristics of characteristics of monitoring minimized after
in insicion site” related to goal: pain. pain effectiveness of nursing intervention
surgery. Pain will medicine as evidenced by no
Objective data: be complain of pain.
- Keep in - Kept in - It helps to relieve
“patient was controlle
comfortable comfortable pain.
feeling sad and d within
position. position
discomfort due to hour.
- Provide -Provided -Relief of pain
pain” Long
analgesic as analgesic as
term
order. order.
goal:pain - Apply -Applied -Refocuses attention
will be diversional diversional promotes relaxation
controlle therapy therapy. and may enhance
d through coping abilities.
hospitaliz
ation.

56
Date Assessmen Nursing Nursing goal Planning Implementation Rationale Evaluatio
t Diagnosis n
2073/ Subjective: Fear of Short term To assess the Assessed patient’s Helps to find out Patients
10/21 Patient says death and goal: anxiety level, anxiety level and base line data. was being
“ I am anxiety Patient will noting patient’s noted patient’s relaxed
worrying related to express being verbal and non verbal and non ,stress free
about change in relax and able verbal response. verbal response. and
disease health to take rest expressing
condition” status as after To identify the Identified source of Helps patient to deal his feeling
evidenced implement of source of fear fear and provided realistically with as
by intervention. and provide accurate information disease.s evidenced
expressed Long term accurate (complication of by
concern goal: patient information. surgery in stomach verbalizati
regarding will be stress cancer). on.
Objective: changes. free through To explain Patient was
-anxious out about the explained about the Helps to relieve the
-hopeless hospitalization prognosis of prognosis of disease fear related to
and onward. disease condition. disease.
condition.
To make Patient was
patients interacted with other Helps to gain
interaction with patient with similar strength and promote
other patient of disease condition. coping.
similar disease
condition.

57
S Assessment Nursing Nursing goal Planning Implementation Rationale Evaluatio
Diagnosis n
.
N
Subjective: Impaired Short term To assess general Assessed Weight serves as an Patient
Patient said that nutrition less goal: condition and to monitor general assessment tool to seems to
“ I don’t like to than body patients weight. condition and determine the adequacy of be
eat food and I requirement Patient will monitored nutritional intake. energeti
am feeling related to gain usual patient weight. c than
weak’’ anorexia as energy level (60 kg). before
evidenced by during Encourage patient to eat Small and soft Small frequent meal will as
Objective: weight loss. hospitalizatio small amount of food diet was help to maintain nutritional evidence
n. frequently and eat soft and provided. status. And soft and non- d by his
 weak non-irritating food. irritating food are easily expressi
 lethargy Long term digestible. on.
goal: Provide food of Food of Food if interest arises
preference and promote preference was appetite and oral health
Patient oral care provided and also promotes appetite.
nutritional oral hygiene
status will be maintained.
maintained by Serve preferred food in an Food if interest To increase and stimulate
demonstrating attractive manner. arises appetite appetite.
stable weight and oral health
by 1 month. also promotes
appetite.

58
S. no Assessment Nsg Nsg goal Planning implementatio Rationale Evaluation
Diagnosis n

2073/10/2 Objective Risk for Short term -give catheter care -catheter care To prevent Infection
data infection goal: daily with sterile was given from urinary was
0 related to technique
I/V line daily in tract infection minimized
invasive To minimize as evidenced
catheter ,NG morning
tube and procedures. the risk of by normal
infection. -alternate day -dressing was - It prevents body
abdominal
dressing with sterile done with growth of temperature.
drain was Long term
kept . technique sterile microorganism
goal: to
technique
minimize the
risk of - abdominal drain -abdominal -it prevent
infection care daily drain care was growth of
during done daily microorganism
hospitalizatio .
n
-Assess I/V line for -asessed the -to reduce
redness,swelling,pain site of iv line infection

Monitor vital sign -monitered -elevated body

respiration, pulse vital sign 2 temperature
temperature. hourly and
tachycardia is
of infection

-advice patient to -Adviced -Protein diet

take high protein patient to take promotes

59
 diet. high protein wound healing
diet food fast.

S. Assessme Nursing Nursing Planning Implementation Rational Evaluati

N nt Diagnosis Goal on
5. Objective Risk of chest Short -Positioning -Position patient in -it helps in easy breathing Infection
data: infection term of patient mid or high fowlers was
Immobility related to goal: To position minimized
ineffective make -Encourage -its helps to remove the as
airway airway -Encouraged patient to evidenced
deep breathing secretion.
clearance clearance turn and breathe deep by no
and coughing.
secondary to Long at least twice a day. chest
post operative term -To assist in -encouraged to -Removes the secretion infection..
procedure. goal; To ambulation ambulate.
reduce -To provide -Provided steam It helps to liquify the
the risk steam inhalation secretion
of chest inhalation
infection To provide -Encouraged to drink It helps to thining of

during liquid diet. plenty of fluids secretion.

60
 hospitaliz
ation.

DAILY PROGRESS NOTE

DATE VITAL SIGNS INTAKE GENERAL CONDITION
/OUTPUT
2073/10/22 BP-110/70mmhg Intake=2500ml Patient condition was alert.Today is 4th post op day. No
P=76b/m Output=2550ml soakage in dressing .All suture present. NG tube free drain
Resp=18/m Temp=980F present. NPO. Bladder and bowel habit intact .Abdominal
drain present .ambulation done.
2073/10/23 BP-110/80mmhg Intake2500ml Patient condition alert. Today 5th post Op day. Closed wound
P=72b/m Output=2000ml .Bladder and bowel habit intact. NPO. Abdominal drain
Resp=18/m Temp=980F present.NG free drain.

2073/10/24 BP-110/70mmhg Intake=2500ml Patient condition alert .Today is 6th post op day. .Orally 500ml
P=100b/m Output=2000ml ORS.Foleys out done . closed wound.
Resp=18/m
Temp=100.20F
2073/10/25 BP-110/60mmhg Intake=1500ml Patient condition alert. Today is 7th post op day .Orally liquid
P=72b/m Output=1550ml diet upto 1litre as tolerated .Dressing is done.NG was
Resp=18/m Temp=980F removed

61
2073/10/26 BP-120/70mmhg Intake=1500ml Patient condition alert. Today is 8th post op day . Orally soft
P=76b/m Output=1200ml diet is allowed .
Resp=18/m Temp=980F

2073/10/27 BP-120/60mmhg Patient condition alert .Today is 9th post op day .Orally
P=74b/m normal diet is allowed .Abdominal drain is present.oral
Resp=18/m Temp=980F medication.
2073/10/28 BP-110/70mmhg Patient condition alert. Today is 02th post op day .Dressing is
P=74b/m done .Bladder and bowel habit intact .abdominal drain out.
Resp=18/m Temp=980F

62
 STRESS MANAGEMENT

• Following measures were taken for stress management in my patient:-

• Build a good rapport with the patient and family members.
• Gave complete orientation about ward, routine of wards, rules and regulations.
• Thoroughly explained about disease condition, its management and modification
therapies etc.
• Be available to the patients and visitors when they want to discuss their feelings.
• Offer kindness, concerns, consideration and sincerity towards child and parents.
• Offer hope that therapy will be effective and will prolong life.
• Provide opportunities to have parents to parents, guardians to guardians talking.
• Provided opportunities to ventilate his feeling in family members.
• Advised to make coping strategies:-positive thinking, set priorities and limits and
develops sense of humor.

DIVERSIONAL THERAPY AND ITS RESULT:

It is difficult to adjust in a new environment and takes time to adjust for every
individual especially. It is difficult for him to cope with stress.

He had suffered from many problems that is fear of new environment, anxiety from
illness, fear of death, productivity, separation anxiety, economic problem are the major
stressors during hospitalization.

Stress management and diversional therapy are the most important to minimize the
patient’s and family’s stress. Diversional therapy encompasses those activities that are
recreational and pursued during leisure time for purpose of satisfaction. Following are
the diversional therapies that I use for my patient:

63
1. Talk Therapy:
I encouraged him to explore his feeling and fears towards illness and hospitalization.
Furthermore I identified his interests and talked about his family, home environment,
friends and his further future preparations.

2. Touch therapy:
Touch is the first sense to become functional throughout the life span. Gently touching
another person conveys affection and friendliness. Touch is a therapeutic tool so that I
used to help the patient meet the comfort needs. It provides sensory stimulation,
reduce anxiety, orient the patient to reality and relieve physiological and emotional
pain. So I used touch therapy for diverting his mind and to relieve emotion pain and
reduce anxiety.
3. Play therapy:
Due to hospitalization and immobility, the patient cannot be provided the outdoor
games but encouraged to play the bed side games like ludo .
4. Music therapy:
Music acts as an crucial role in curing disease patient by reducing stress. I advised
visitor to bring cell phone and allowed patient to listen current news and music.
5. I further encouraged my patient to interact with the surrounding patients and
share their feelings.
6. Reinforcement:
Reinforcement also plays a vital role to divert the patient mind from stressful situation,
so that I reinforce the patient to divert his mind in following ways.
I watched for small changes in behavior that indicate progress and rewarded behaviors.
I rewarded patient for correct behavior with verbal praise, touch and smiles.

Result of diversional therapy:

Diversional therapy has an important role in patient’s life. It provides patients with
physical and mental strength. It will divert patients mind from emotional, frustrating
and stressful situation.

I had provided many diversional therapies activities to my patient then I found that
patient and his family had minimal stress.

As a result of the diversional therapy he becomes better to cope with stressors of

illness and hospitalization. Therefore diversional therapy became successful to
minimize the stress of patient illness and hospitalization.

64
HEALTH EDUCATION DURING HOSPITALIZATION
During hospitalization of patient, health education was provided to both patient & his
family. Broadly viewed, health education was focused on biologically psychological
and social parameters.

The health education was provided on the following things for health promotion.

 Nutrition
 Physical care and maintenance of hygiene
 Sleep and rest and activities.
 Dental care/skin care
 Drug therapy
 Regular check up / follow up
 Managing symptoms
 Prevent from any complication
1. Nutrition:-
patient needs the nutritious foods diet should be non irritating so patients family was
known about the nutrition. Provide food containing vitamins like A, C & K, containing
food. Encourage on fibrous diet and more fluid diet.
2. Physical care and maintenance of hygiene
It should be maintained to prevent from infection. Encourage the patient in self – care.
3. Sleep & Activities
The importance of sleep period requirement is to prevent from exertion and helps to
maintain physically and psychologically healthy.
4. Dental Care
Patient has anorexia. If daily oral care is not performed he may loses the appetite. So
the patient needs daily oral care. It helps to refresh the patient, stimulate appetite, and
relive bad smell in breath by removing the oral debris. It prevents from oral infection.
5. Drug Therapy
Patient is advised for regular taking of drug after going home. Because irregular
medication does not work.

6. Follow-up
The necessity of follow up of patient after discharge was discussed with the patient
and his family. The productivity of follow up regarding patient’s improvement was
discussed.

7. Symptoms
If signs of dyspnoea, fever, dizziness, haemorrhage occur, call on duty nurse and
doctor.

65
8. Prevent from complication
Encourage patient to take adequate amount of fluid to prevent UTI, deep breathing &
coughing exercise to prevent respiratory complication, roughage food to prevent
constipation and skin care to prevent bed sores.

9. Adopting an activity Programmed

Engage in regimen of physical activity with gradual increase of activity duration and
gradual increase activity intensity.

Medication on discharge
• Tab Rab 20 mg p/o BD for 1 month
• Tab Hybro 20 mg po OD for 1 month
• Syp Amalylure D5 10 ml po TDS for 1 month
• Syp Arozyme 10 mlpo BD for 1 month
• Cap Spistd 1 cap po BD for 1 month

66
DISCHARGE TEACHING
Discharge teaching is an integral part of nursing process. My patient was discharged
on 13th day of admission.
Objectives of discharge teaching are:
 To provide relevant health teaching and information
 To maintain and promote health and prevent further illness at home.
 To seek early health facility for proper treatment.
 To encourage doing self care.
Content of Discharge teaching:
 Diet
 Medication
 Exercise
 Rest and sleep
 Personal hygiene and environmental sanitation
 Improving communication
 Maintain taste sensation
 Psychological support
 Elimination

 Diet :
- I advised patient to take small, frequent food in proper ratio.
- Avoid alchohol,smoking habit.
- Take balance diet in proper ratio.
- Avoid spicy diet

 Medication:
- I provide all information relating to medication including dose, side effect to
the patient and family.
-Encouraged to take full course of prescribed medication at right time, dose
and duration.

 Exercise
- I advised patient to ambulate during morning and evening according to his
ability.
- Avoid heavy work but encourage for light work such as morning care.
- Perform ROM exercise to all body joints every 2-4 hours.
- If unable to do exercise, involve family member in providing exercise.

67
 Rest and Sleep :
-Most requires minimum 8-10 hours rest and sleep and time at night and 2-3
hours in day time at night and it is based on disease condition.
- I encourage him to avoid stress, anxiety and fatigue and have adequate rest
and sleep.

 Personal hygiene and environmental sanitation :

- I advised him to remain in clean and quite environment.
- Maintaining body temperature and room temperature.
- Avoid exposure to polluted environment.
- Provide safety environment and safety measure.

 Maintain taste sensation :

- I advised him to have oral care daily.
- Ask or daily asses the patient ability for taste.

 Improving communication :
- Provide strong moral support.

 Psychological support :
- Relive him from anxiety.
- Divert mind by making diversonal therapy.
-
 Elimination:
- I provide him education how to prevent from diarrhea and constipation,
- I advised him that regular elimination habit should be made.

68
 FOLLOW UP VISIT
The care of the patient does not end after the discharge from the hospital. It continues until
the follow up of the patient is done. Follow up visit is very important for the evaluation of
the general condition and progress of the patient.
The main objectives of follow up visit are as follows,
 To assess the health status of the patient
 To find out progress of the patient’s condition.
 To evaluate the use of knowledge and skill which they have learnt in the hospital.
 To know the further problem
 To help the patient to manage problem.
 To prevent further complication.
 To develop the self esteem of the patient.

•My patient was discharged on 2073/10/23 after 13 days of hospital stay

•He was advised for follow up after 10 days and if necessary.
•If any problem arises related to disease immediately consult with physician.

WHAT I LEARNED FROM THE CASE STUDY

The case study about stomach cancer provided me an opportunity to provide holistic care to
the patient and comprehensive study about the disease. During the case study, I learned
various things which are as follows

 I gained in depth knowledge about stomach cancer, its causes, pathophysiology, clinical
manifestation, diagnosis, investigation, medical management, complication and nursing
management.
 It provided me detailed knowledge about drugs used in my patient.
 I learned to apply nursing process in detail.
 I used well prepared nursing care plan in caring my patient.
 I learned about patients personal, social and spiritual aspects clearly through different
aspects.
 I learned about reporting and documenting about patient condition.

At last I learnt comprehensive study, complete case study and ways of preparing and
presenting it and increased confidence for case studies in future.

69
SUMMARY

For the completion of requirement of my course, I have completed a case study on“Stomach
Cancer” at B.P. Koirala Memorial Cancer Hospital over 2 weeks posting from 2073/10/18 to
2073/10/28.

My patient is Mr. Keshav Bahadur Karki was admitted at Surgical Oncology Department in
bed no 97 on 2073/10/10with diagnosis of stomach cancer . He had undergone surgery on
2073/10/11 and gastrojejunotomy was done .. I provided nursing care to maintain health and
prevent infection due to surgical state. He has shown good compliance with medicine. I
provided health education regarding diet, hygiene, rest and side effects of medicines to patient
and family. I also applied Orem’s Self Care Deficit theory to provide care to my patient.

His condition was improved day by day by providing good care and finally he was
discharged on 2073/10/23 and advised for follow up after 14 day

During the course of this case study my communication skill was also developed with patient,
visitors, doctors, ward sisters & other members involved in the health team. At last I want to
say that case study is the best method to gain knowledge,skill & attitude which is very
important for the students.

70
BIBLOGRAPHY
Lewis, Dirksen, Heitkemper, & Bucher. (2015). Lewis's Medical-Surgical Nursing (2nd ed., Vol. 2). India:
Reed Elsevier India Private Limited,Page no.696-701.

Basavanthappa, B. (2015). Medical Surgical Nursing (3rd ed., Vol. 2). Jaypee Brothers Medical
Publishers,Page.no.1024-1028.

Rai, L. (2011). Nursing Concepts, Theories and Principles (2nd ed.). Kathmandu, Nepal:
Mr.Nabin Kumar Rai, page.no.190-198

Nursing Inservice Unit, Department Of Nursing. (2014). Oncology Nursing Manual (2nd ed.). Chitwan,
Nepal: B.P. KoiralaMemorial Cancer Hospital,Page. no.136-137.

Tripathi, K. D. (2013). Essential of Medical Pharmacology (7th ed.). New Delhi: Jaypee Brothers
Medical Publishers (P) Ltd.page no; 288-289,653,.
Tuitui, R. (2008). Pocket Book of Drugs (4th ed.). Makalu Publication.page no; 181,168,219.
Tuitui, R., & Suwal, S. N. (2013). Human Anatomy and Physiology (7th ed.). Vidhyarthi prakashan (P.)
Ltd.
williams, & wilkins. (2014). Lippincott Manual of Nursing Practice (10th ed.). Wolters Kluwer (India)
pvt.Ltd.,New Delhi .

71