Casestudy Gastric Carcinoma

1 Case Study: Gastric Carcinoma
OBJECTIVES
General:
This case presentation aims to identify and determine the
general health problems and needs of the patient with an
admitting diagnosis of Gastric Carcinoma. This study also intends
to help promote health and medical understanding of such
condition through the application of the nursing skills.
Specific:
 To enhance knowledge and acquire more information about
Gastric Carcinoma
 To give an idea of how to render proper nursing care for
clients with this condition thus it can be applied for future
exposures of students
 To gather the needed data that can help to understand how
and why the disease occurs
 To identify laboratory and diagnostic studies used in Gastric
carcinoma
 To enumerate the clinical manifestations of the disease so as
to provide prompt intervention of its occurrence.
ACKNOWLEDGEMENT
First and foremost, I would like to express my sincerest

gratitude to our Almighty God for giving me the ability and chance
to finish this study and for guiding me in my everyday life and
activities.
I also wish to express my deepest gratitude to my family for

providing me everything I need and for their untiring support.
I also thank my friends for their constant encouragement.
And to the patient and her relatives, I want to extend my

gratitude for their cooperation and for giving me the informations I
need to finish this requirement.
It is also my pleasure to thank the Dean of College of

Nursing, Dean May Veridiano for being always considerate and
approachable and for establishing a good quality of education in
our department. And to all our instructors/faculty members,I thank
them fortheir guidance and all the knowledge, discipline, and
lessons they have shared to us.
Finally, I thank my most beloved teachers and those special

people who made me feel that they believe in me more than I do
to myself.
INTRODUCTION:
Background of the
Disease
Gastric Carcinoma
Gastric carcinoma is the most common cancer in the world after lung and
is a major cause of mortality and morbidity. Though a marked reduction has been
observed in the incidence of gastric carcinoma in North America and Western
Europe in the last 50 years, 5-year survival rates are less than 20%, as most
patients present late and are unsuitable for curative, radical surgery.
Gastric cancer can develop in any part of the stomach and may spread
throughout the stomach and to other organs; particularly the esophagus, lungs,
lymph nodes, and the liver. Stomach cancer causes about 800,000 deaths
worldwide per year.
Types:
There are several Hystological types of Gastric Cancer of which
adenocarcinoma is by far the most frequent. Sarcomas and Lymphomas
can also occur.
Risk Factors:
Risk factors for gastric lymphoma include the following:
 Helicobacter pylori
 Long-term immunosuppressant drug therapy
 HIV infection
 aged between 50 and 59
 Blood Group A
Clinical Manifestations:
Stomach cancer is often asymptomatic or causes only nonspecific symptoms in
its early stages. By the time symptoms occur, the cancer has generally metastasized to
other parts of the body, one of the main reasons for its poor prognosis. Stomach cancer
can cause the following signs and symptoms:
Early
 Indigestion or a burning sensation (heartburn)
 Loss of appetite, especially for meat
Late
 Abdominal pain or discomfort in the upper abdomen
 Nausea and vomiting
 Diarrhea or constipation
 Bloating of the stomach after meals
 Weight loss
 Weakness and fatigue
 Bleeding (vomiting blood or having blood in the stool) which will appear as black.
This can lead to anemia.
 Dysphagia; this feature suggests a tumor in the cardia or extension of the gastric
tumor in to the esophagus.
These can be symptoms of other problems such as a stomach virus, gastric

ulcer or tropical sprue and diagnosis should be done by a gastroenterologist or
an oncologist.
Specific signs and symptoms for gastric lymphoma
 Epigastric pain
 early satiety
 fatigue
 weight loss
 Nausea and Vomiting
 Anorexia
 Weakness
 Dysphagia
Staging
If cancer cells are found in the tissue sample, the next step is to stage, or find out
the extent of the disease. Various tests determine whether the cancer has spread and, if
so, what parts of the body are affected. Because stomach cancer can spread to the
liver, the pancreas, and other organs near the stomach as well as to the lungs, the
doctor may order a CT scan, a PET scan, an endoscopic ultrasound exam, or other
tests to check these areas. Blood tests for tumor markers, such as carcinoembryonic
antigen (CEA) and carbohydrate antigen (CA) may be ordered, as their levels correlate
to extent of metastasis, especially to the liver, and the cure rate.
Staging may not be complete until after surgery. The surgeon removes nearby
lymph nodes and possibly samples of tissue from other areas in the abdomen for
examination by a pathologist.
TNM staging is used
 T stage - Extent of penetration through the gastric wall
o Tis - Carcinoma in situ, intraepithelial tumor
o T1 - Tumor extension to submucosa
o T2 - Tumor extension to the muscularis propria or subserosa
o T3 - Tumor penetration of the serosa
o T4 - Tumor invasion of the adjacent organs
 N stage - Number and site of draining lymph nodes involved (see also N staging
in the CT Scan, Findings section, below)
o N0 - No lymph nodes involved
o N1 - Metastases in 1-6 regional lymph nodes
o N2 - Metastases in 7-15 regional lymph nodes
o N3 - Metastases in >15 regional lymph nodes
 M stage - Presence of metastases
o M0 - No distant metastases
o M1 - Distant metastases
Preferred Examination
 Begin the evaluation with history taking and physical examination.

 Perform blood tests, including a full blood count determination and liver function
tests.
 Inspect the stool, and test for occult blood.
 Perform either fiberoptic endoscopy or a double-contrast study (barium and gas)
of the upper GI tract.
o Endoscopy has become the diagnostic procedure of choice for patients
with suspected gastric carcinoma. Biopsy samples obtained during
endoscopy enable histologic diagnosis. However, endoscopy is more
invasive and more costly than a double-contrast study.
o Double-contrast examinations of the upper GI tract remain a useful
alternative to endoscopy and have similar sensitivity in the detection of
gastric cancer.
 CT, MRI, and endoscopic ultrasonography (EUS) are used in staging but not
usually in the primary detection of gastric cancers (see the CT Scan, MRI,
and Ultrasound sections).
Diagnosis:
To find the cause of symptoms, the doctor asks about the patient's medical
history, does a physical exam, and may order laboratory studies. The patient may also
have one or all of the following exams:
 Gastroscopic exam is the diagnostic method of choice. This involves insertion of

a fiberoptic camera into the stomach to visualize it.
 Upper GI series (may be called barium roentgenogram)
 Computed tomography or CT scanning of the abdomen may reveal gastric
cancer, but is more useful to determine invasion into adjacent tissues, or the
presence of spread to local lymph nodes.
Abnormal tissue seen in a gastroscope examination will be biopsied by

the surgeon or gastroenterologist. This tissue is then sent to
a pathologist for histological examination under a microscope to check for the presence
of cancerous cells. A biopsy, with subsequent histological analysis, is the only sure way
to confirm the presence of cancer cells.
Various gastroscopic modalities have been developed to increased yield of
detect mucosa with a dye that accentuates the cell structure and can identify areas of
dysplasia. Endocytoscopy involves ultra-high magnification to visualize cellular structure
to better determine areas of dysplasia. Other gastroscopic modalities such as optical
coherence tomography are also being tested investigationally for similar applications.
A number of cutaneous conditions are associated with gastric cancer. A condition

of darkened hyperplasia of the skin, frequently of the axilla and groin, known
as acanthosis nigricans, is associated with intra-abdominal cancers such as gastric
cancer. Other cutaneous manifestations of gastric cancer include tripe palms (a similar
darkening hyperplasia of the skin of the palms) and the sign of Leser-Trelat, which is the
rapid development of skin lesions known as seborrheic keratoses.
Possible Complications
 Fluid buildup in the belly area (ascites)
 Gastrointestinal bleeding
 Spread of cancer to other organs or tissues
 Weight loss
Outlook/Prognosis
The outlook varies widely. Tumors in the lower stomach are more often cured
than those in the higher area -- gastric cardia or gastroesophageal junction. The depth
to which the tumor invades the stomach wall and whether lymph nodes are involved
influence the chances of cure.
In circumstances in which the tumor has spread outside of the stomach, cure is
not possible and treatment is directed toward improvement of symptoms.
DEFINITION OF TERMS
 Dysphagia – difficulty in swallowing
 Sprue - a chronic form of malabsorption syndrome, occurring in both
tropical and nontropical forms.
 Carcinoembryonic Antigen - a glycoprotein found in serum, urine,
etc. that is associated with various types of tumors: monitoring its
levels is useful in treating cancer patients.
 Acanthosis nigricans- A skin condition characterized by dark
thickened velvety patches, especially in the folds of skin in the axilla
(armpit), groin and back of the neck.
 Leser-Trelat Sign – sudden appearance and rapid increase in
number size of seborrhoeic keratoses withpruritus; associated with int
ernal malignancy.
 Seborrheic Keratosis – A superficial, benign, verrucose lesion
consisting of proliferating epidermal cells enclosing horn cysts,
usually appearing on the face, trunk, or extremities in adulthood.
 H. pylori - the type species of genus Heliobacter; produces urease
and is associated with several gastroduodenal diseases (including
gastritis and gastric ulcers and duodenal ulcers and other peptic
ulcers)
 Intraperitoneal Hyperthermic Chemotherapy – Oncology The
administration of heated chemotherapeutics in solution circulated in
the peritoneal cavity.
 Metastasis – Transmission of pathogenic microorganisms or
cancerous cells from an original site to one or more sites elsewhere
in the body, usually by way of the blood vessels or lymphatics.
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 Ascites – is excess fluid in the space between the tissues lining the
abdomen and abdominal organs (the peritoneal cavity)
 Risk Factors – anything that increases a person’s chance of
developing a disease
 CHOP is the acronym for a chemotherapy regimen used in the
treatment of non-Hodgkin lymphoma
 Mutation – occurs when a DNA gene is damaged or changed in such
a way as to alter the genetic message carried by that gene.
Personal
Background of the
Patient
1
PERSONAL DATA
Name: Patient X
Address: Masin Norte Candelaria, Quezon
Occupation: none
Religion: Iglesia ni Cristo
Nationality: Filipino
DEMOGRAPHIC DATA
Date of Birth: May 6, 1954
Place of Birth: Candelaria, Quezon
Age: 55 years old
Gender: Female
Civil Status: Married
PATIENT PROFILE
Date Admitted: February 28, 2010
2
3:00 pm
Attending Physician: Dr. Leonardo Holguin
Room: Female Surgical Ward 3
Hospital Record No: A-03317
ER No: E-05380
HOME ENVIRONMENT
Physical Environment: Living with her husband and 2 children
SLEEP AND REST PATTERN

Usual Sleep Pattern: Usually sleeps at 9 o’clock in the evening and
awakes at 5 o’clock in the morning. But during
hospitalization, she frequently sleep even on
daytime.
Relaxation Techniques: Sleeping and watching television are his
relaxation technique.
ELIMINATION PATTERN
Urinary: He urinates 3-4 times a day.(before
hospitalization)
With catheter(during hospitalization)
Bowel: He defecates three to four times week.(before
hospitalization)
With foley catheter,jejunostomy(during
hospitalization)
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PAST HEALTH HISTORY

Past Medical History
She has no history of previous confinement, surgery or another
chronic illness.
Medications
Paracetamol (Biogesic)
Robitusin
Mefenamic Acid
Allergies
No known allergies to food and drugs
Family History
Hypertension(Father)
HISTORY OF PRESENT ILLNESS
Reason for seeking medical care: Loss of Appetite

Weight Loss
Six months prior to admission, the patient noticed difficulty of

swallowing solid foods. And she had a significant weight loss. And two
weeks prior to admission, she experienced early satiety and fullness
which was relieved by vomiting. Her condition then progressed to
recognizable vomiting of undigested food after meals especially with
solids. Since then, she experienced anorexia because of progressing
difficulty of breathing. No symptoms of upper gastrointestinal bleeding.
She could tolerate fluid and small amount of soft diet. Upon admission,
she had been experiencing burning epigastric pain. Passing urine and
bowel opening were normal.
 NPO
4
 With D5NSS
5
PHYSICAL
EXAMINATION
Vital Signs
Upon Admission Latest
Temperature 36.5°C 36.5°C
Pulse 90beats/min 76beats/min
Respiration 25breaths/min 23breaths/min
Blood Pressure 110/90mmHg 110/80mmHg
HEAD
Skull and Face
 Rounded, normocephalic and symmetrical
 Uniform consistency; absence of nodules or masses
 Symmetric facial movements
 No tenderness
6
 Can move facial muscles at will
SCALP
 Dry
 Free from lice and nits
 No tenderness nor masses
 Lighter in color than the complexion
SKIN
 The skin color is pale
 No skin abrasions or lesions
 No edema present
 Dry skin
 Temperature is within normal range
HAIR
 Evenly distributed hair
 Black
 Variable amount of body hair
NAILS
 Convex curvature
 Smooth in texture
 Pale
 With capillary refill of 1-2 seconds
Eyes,Eyebrows and Eyelashes

 Eyebrows symmetrically aligned
 Equally distributed eyelashes
 Skin intact ; no discharges
 Sclera appears white; capillaries are evident
 Conjunctiva appears shiny, smooth and pink
 No edema or tenderness present over lacrimal gland
Conjunctiva
 Pale
 moist
 Transparent, shiny and smooth cornea
 Pupils is black in color, equal in size and reactive to light
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Ears
 Auricle symmetrical, aligned with outer canthus of the eyes
 Mobile, firm and not tender,; pinna recoils after it is folded
 Normal voice tones audible
Nose and Sinuses

 External nose is symmetric and straight
 Clear-watery discharge and flaring of the nares
 Uniform in color
 No tenderness or lesions when palpated
 Airway is patent (air moves freely as the client breathes through
the nares
 Nasal septum intact and in midline
Mouth and Oropharynx

 Outer lips is pale and dry
 Tongue in central position, pink in color; with raised papillae;
moves freely
 Dysphagia
NECK
 Neck muscles equal in size, head is centered
 Coordinated, smooth movements without discomfort
 With palpable lymph nodes
THORAX AND LUNGS

 Chest symmetric
 Skin intact; uniform temperature
 Chest wall intact; no tenderness, no masses
 Clear breath sounds
 Not in respiratory distress
ABDOMEN
 Uniform in color
 With intact dressing on postoperative site
 With foley catheter/jejunostomy
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MUSCULOSKELETAL SYTEM
 Equal in size on both sides of body
 No contractures; no tremors
 Coordinated movements
 Malaise/weakness
 Thin extremities
 Decreased Activity Tolerance
EXTREMITIES
 No edema
 Symmetric
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Laboratory
Examinations
CT Scan
Case no: 10-0047
Abdomen: flat,soft
(+) palpable mass 5x5mm epigastric area
(-)edema
Report:
Multiple axial tomographic sections of the abdomen without contrasts were
obtained. CT images show a circumferential diffuse thickening of the stomach
wall with a narrowed gastric lumen. The wall measures 20mm in diameter.
The liver, pancreas and spleen are normal in size and homogeneity.
No focal masses, calcifications or lymphadenopathies noted.
The kidneys are normal in size, position and configuration with mild dilatation of
the right renal pelvis.
The rest of the soft tissue vascular and osseous structures are normal.
0
Impression:
Thickened Gastric Wall
Primary consideration is Gastric Lymphoma
Suggest Endoscopy
Radiology
Suspicious infiltrates in right upper lung fields, normal heart shadow
Impression:
Suggest Lordotic View
Ultrasound
Impression:
Epigastric mass, (?)Etiology r/o right renal pathology
Blood Chemistry
Result Normal values Interpretation

RBS 148 70-110mg/dl Increased: hyperglycemia
PPBS 131 <140 Normal
Creatinine 0.5 0.5-1.7 Within normal range
Sodium 142.3 135-148mol/L Within normal range
Potassium 3.31 3.5-5.3mmol/L Decreased:
hyperparathyroidism,vit.
D deficiency,GI losses
Miscellaneous
Prothrombin Time
Pt’s PT 14 secs 10-14 Within normal range
INR 1.2 0.8-1.3 Within normal range
%Activity 72.3% 70-100% Within normal range
Urinalysis
1

Color Dark yellow Yellow Concentrated,sometimes due to
some drugs
Transparency Turbid Clear Semen, mucus, and lipid may cause
turbidity.Increased numbers of
cells, crystals, casts, or
organisms can increase the
turbidity of urine in disease
conditions.
Reaction 6.0 4.8-7.8 Normal
Sp.Gravity 1.030 1.015-1.025 Increased:dehydration
Albumin Trace (-) may result from excessive muscular
exertion, convulsions, or excess
protein ingestion,kidney disease
Sugar (-) (-) Normal
Pus cells 1-3 0-2/hpf Increased: sign of an infection or
inflammation in the kidneys, bladder or
another area
RBC 1-3 0-1/hpf Increased: glomerular damage,
tumors which erode the urinary
tract anywhere along its length,
kidney trauma, urinary tract
stones, renal infarcts, acute
tubular necrosis, upper and
lower urinary tract infections,
nephrotoxins, and physical
stress
Epith cells Few +,few Normal
Mucus threads Plenty +,few mucosal surface irritations
Amorphous few few Normal

Urates
Hematology

9/L
WBC 5.2 5-10x10 Within normal range
Neutrophils 69 55-65 Increased: acute infections,
trauma or surgery, leukemia,
malignant disease, necrosis
Lymphocytes 28 25-35 Within normal range
2
Eosinophils 01 1-5 Within normal range

Monocytes 02 1-6 Within normal range
HgB 11.5 M 13.5- Decreased: various anemias,
18.0g/dl pregnancy,severe or prolonged
F 12.0-16.0g/dl hemorrhage, and with excessive
fluid intake
Hct 0.37 M 0.40- Within normal range
0.48g/dl
F 0.37-0.45g/dl
Platelet adequate 150-400x109/L Normal
Blood type A positive ---------
Others
MCV 65.6 80.0-99.9fi Decreased: RBCs are
smaller than normal
(microcytic) as is seen
in iron deficiency
anemia or thalassemia
s
MCH 20.3 27.0-31.0pg Decreased: microcytic red
cells
MCHC 30.9 33.0-37.0g/dl Decreased: (hypochromia)
are seen in conditions
where the hemoglobin
is abnormally diluted
inside the red cells,
such as in iron
deficiency anemia and
in thalassemia
3
Anatomy
and Physiology
Digestive System
4
The organs of digestive system can be separated into two main groups: those
forming the alimentary canal, and the accessory digestive organs. The alimentary
canal performs the whole menu of digestive functions while the accessory organs assist
the process of digestive breakdown in various ways.
Organs of the Alimentary Canal

5
The alimentary canal, also called the gastrointestinal tract, is a continuous, coiled,
hollow, muscular tube that winds through the ventral body cavity and is open at both
ends. Its organs are the mouth, pharynx, esophagus, stomach, small intestine and
large intestine. The large intestine leads to the terminal opening or anus. In a cadaver
the alimentary canal is approximately 9 m (about 30 feet) long, but in living person, it is
considerably shorter because of its relatively constant muscle tone. Food material within
this tube is technically outside the body, because it has contact only with cells lining the
tract and the tube is open to the external environment at both ends.
Mouth
Food enters the digestive tract through mouth
or oral cavity, a mucous membrane- lined cavity. The
lips protect its anterior opening, the cheeks form its
lateral walls, the hard palate forms its anterior roof,
and the soft palate forms its posterior roof. The uvula
is a fleshy fingerlike projection of the soft palate, which
extends downward from its posterior edge. The space
between the lips and cheeks externally and the teeth
and gums internally is the vestibule. The area contained by the teeth is the oral cavity
proper. The muscular tongue occupies the floor of the mouth. The tongue has several
body attachments – two of these are to the hyoid bone in the styloid processes of the
skull. The lingual frenulum, a fold of mucous membrane,
secures the tongue to the floor of the mouth and limits its
posterior movements.
Pharynx
From the mouth, food passes posteriorly into the
oropharynx and laryngopharynx, both of which is common
passageway for food, fluids and air. The pharynx id
subdivided into the nasopharynx, part of the respiratory
passageway; the oropharynx, posterior to the oral cavity; and the laryngopharynx,
which is continuous with the esophagus below.
6
Esophagus
The esophagus or gullet runs from
the pharynx through the diaphragm to the
stomach. About 25cm (10inches) long, it is
essentially a passageway that conducts
food to the stomach.
Stomach
The C-shaped stomach is on the left
side of the abdominal cavity, nearly hidden
by the liver and diaphragm. The stomach
acts as a “storage tank” for food as well as
a site for the food breakdown. Chemical
breakdown of proteins begins in the
stomach. The mucosa of the stomach is a
simple columnar epithelium that produces
large amounts of mucus.
Most digestive activity occurs in the
pyloric region of the stomach. After food
has been processed in the stomach, it
resembles heavy cream and is called chime. The chime enters the small intestine
through the pyloric sphincters.
Small Intestine
The small intestine is the body’s major digestive organ. Within its twisted
passageways, usable food is finally prepared for its journey into the cells of the body.
The small intestine is a muscular tube extending from the pyloric sphincter to the
ileocecal valve. It is the longest section of alimentary tube with an average length of 2.5-
7m (8-18 feet) in a living person.
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The small intestine has three subdivisions: the duodenum (“twelve finger widths
long”), the jejunum (“empty”) and the ileum
(“twisted intestine”), which contribute 5 percent,
nearly 40% and almost 60% of the length of the
small intestine. The ileum joins the large intestine
at the ileocecal valve.
Chemical digestion of foods begins in the
nearest in the small intestine. The small intestine
is able to process only a small amount of food at
one time. The pyloric sphincter (gatekeeper)
controls food movement into the small intestine
from the stomach and prevents the small
intestine from being overwhelmed. Though the C-shaped duodenum is the shortest
subdivision of the small intestine, it has the most interesting features. Some enzymes
are produced by intestinal cells. More important are enzymes produced by the pancreas
which are ducted into the duodenum though the pancreatic ducts, where they complete
the chemical breakdown of foods in the small intestine. Bile also enters the duodenum
through the bile duct in the same area. The main pancreatic and bile ducts join at the
duodenum to form the flash bepatopancreatic ampulla, literally, the “liver- pancreatic
enlargement”. From there, the bile and pancreatic juice travel through the duodenal
papilla and enter the duodenum together.
Nearly all foods absorption occurs in the small intestine.
Large Intestine
8
The large intestine is much larger in

diameter than the small intestine but
shorter in length. About 1.5m (5 feet) long,
it extends from the ileocecal valve to the
anus. Its major functions are to dry out the
indigestible food residue by absorbing
water and to eliminate these residues from
the body as feces. It frames the small
intestine on the tree sides and has three
subdivisions: cecum, appendix, colon,
rectum and anal canal. The saclike cecum
is the first part of the large intestine. Hanging from the cecum is the wormlike appendix,
a potential trouble spot. The colon is divided into several distinct regions. The ascending
colon travels up the right side of the abdominal cavity and makes a turn, the right colic
flexure, to travel across the abdominal cavity as the transverse colon. It then turns again
at the left colic flexure, and continues down the left side as the descending colon, to
enter the pelvis, where it becomes the S-shaped sigmoid colon. The sigmoid colon,
rectum, and anal canal lie in the pelvis. The anal canal ends at the anus which opens to
the exterior.
Accessory Digestive Organs

Salivary Glands
Three pairs of salivary glands empty their secretions into the mouth. The large
parotid glands lie anterior to the ears. The submandibular glands and the small
sublingual glands empty their secretions into the floor of the mouth through tiny ducts.
The product of salivary glands, saliva is a mixture of mucus and serous fluids.
The mucus moistens and helps to bind food together into a mass called bolus, which
makes chewing and swallowing easier.
Teeth
9
We masticate or chew, by opening and closing our jaws and moving them from
side top side while continually using our tongue to move the food between our teeth. In
the process, the teeth tear and grind the food, breaking it down into smaller fragments.
Pancreas
The pancreas is a soft, pink, triangular gland
that extends across the abdomen from the spleen to
the duodenum. It secretes digestive enzymes into the
duodenum, the first segment of the small intestine.
These enzymes break down protein, fats, and
carbohydrates. The pancreas also makes insulin,
secreting it directly into the bloodstream. Insulin is the
chief hormone for metabolizing sugar.
Liver
The liver has multiple functions, but its

main function within the digestive system is to
process the nutrients absorbed from the small
intestine. Bile from the liver secreted into the
small intestine also plays an important role in
digesting fat. In addition, the liver is the body’s
chemical "factory." It takes the raw materials
absorbed by the intestine and makes all the
various chemicals the body needs to function. The liver also detoxifies potentially
harmful chemicals. It breaks down and secretes many drugs.
Gallbladder
The gallbladder small, thin-walled green sac that
snuggles in a shallow fossa in the inferior surface of the liver
when food digestion is not occurring, bile backs up the cystic
duct and enters the gallbladder to be stored. While being stored
in the gallbladder, bile is concentrated by the removal of water.
Later, when fatty food enters the duodenum, a hormonal
stimulus prompts the gallbladder to contract to the duodenum
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PATHOPHYSIOLOGY
1
2
Modifiable Factor: Helicobacter Pylori Non-Modifiable Factors:

Medication(NSAIDS) Infection Age
Lifestyle (Salty foods) Blood type
Hygiene
Renders the mucosa more

vulnerable to acid damage
by disrupting mucous layer,
liberating enzymes and
toxins&adhering to gastric
epithelium
upsets gastric acid secretory physiology to

varying degrees
Altered Gastric Secretion
Development of Gastric Ulcers and tissue injury
Cellular Mutation
Persistent Immune Stimulation of Gastric lymphoid tissue
Gastric Lymphoma
3
Pathophysiology
Helicobacter pylori infection is the cause of most stomach cancer. It is unclear

how H. pylori infection spreads. The bacteria probably spread from one person to
another through poor hygiene as the bacteria may be passed in stools. The bacterium
generally does not invade gastroduodenal tissue. Instead, it renders the underlying
mucosa more vulnerable to acid peptic damage by disrupting the mucous layer,
liberating enzymes and toxins, and adhering to the gastric epithelium. Gastric polyps
are precursors of cancer. Inflammatory polyps may develop in patients taking NSAIDs
and too much salty foods is also a risk factor.
The chronic inflammation induced by H. pylori and damage caused by other factors
upset gastric acid secretory physiology to varying degrees causing an altered gastric
secretion. The increased acid secretion leads to the development of gastric ulcers and
tissue injury. These damages causes cellular mutation or changes in the DNA of the
cells. Immune responses induced by the changes causes persistent stimulation of
gastric lymphoid tissue and development into gastric lymphoma.
4
Preventive
Management and
Treatment
5
Prevention:
Screening Programs
Annual mass screening for gastric cancer has been provided in some countries
with a high incidence of gastric cancer (such as Japan, Venezuela, and Chile) with the
aim of detecting gastric cancer in its earliest stages when the prognosis is better.
Vaccination
Vaccine against Helicobacter Pylori is still in progress.
The following may help reduce your risk of gastric cancer:
 Don't smoke
 Eat a healthy, balanced diet rich in fruits and vegetables
 Taking a medication to treat reflux disease, if present
 Decrease intake of preserved foods
Treatment:
As with any cancer, treatment is adapted to fit each person's individual

needs and depends on the size, location, and extent of the tumor, the stage of the
disease, and general health. Cancer of the stomach is difficult to cure unless it is
found in an early stage (before it has begun to spread). Unfortunately, because
early stomach cancer causes few symptoms, the disease is usually advanced
when the diagnosis made. Treatment for stomach cancer may includes
surgery, chemotherapy, and/or radiation therapy. New treatment approaches such
as biological therapy and improved ways of using current methods are being
studied in clinical trials.
Surgery
Surgery is the most common treatment and is the only hope of cure for
stomach cancer. The surgeon removes part or all of the stomach, as well as the
surrounding lymph nodes, with the basic goal of removing all cancer and a margin of
normal tissue. Depending on the extent of invasion and the location of the tumor,
surgery may also include removal of part of the intestine or pancreas. Tumors in the
lower part of the stomach may call for a Billroth I or Billroth II procedure. Endoscopic
mucosal resection (EMR) is a treatment for early gastric cancer (tumor only involves the
mucosa) that has been pioneered in Japan, but is also available in the United States at
6
some centers. In this procedure, the tumor, together with the inner lining of stomach
(mucosa), is removed from the wall of the stomach using an electrical wire loop through
the endoscope. The advantage is that it is a much smaller operation than removing the
stomach. Endoscopic submucosal dissection (ESD) is a similar technique pioneered in
Japan, used to resect a large area of mucosa in one piece. If the pathologic
examination of the resected specimen shows incomplete resection or deep invasion by
tumor, the patient would need a formal stomach resection.
Surgical interventions are currently curative in less than 40% of cases, and, in
cases of metastasis, may only be palliative.
Chemotherapy
The use of chemotherapy to treat stomach cancer has no established standard of
care. Unfortunately, stomach cancer has not been especially sensitive to these drugs
until recently, and historically served to palliatively reduce the size of the tumor and
increase survival time. Some drugs used in stomach cancer treatment include: 5-
FU (fluorouracil), BCNU (carmustine), methyl-CCNU (Semustine), and doxorubicin
(Adriamycin), as well as Mitomycin C, and more recently cisplatin and taxotere in
various combinations. The relative benefits of these drugs, alone and in combination,
are unclear. Scientists are exploring the benefits of giving chemotherapy before surgery
to shrink the tumor, or as adjuvant therapy after surgery to destroy remaining cancer
cells. Combination treatment with chemotherapy and radiation therapy is also under
study. Doctors are testing a treatment in which anticancer drugs are put directly into the
abdomen (intraperitoneal hyperthermic chemoperfusion). Chemotherapy also is being
studied as a treatment for cancer that has spread, and as a way to relieve symptoms of
the disease. The side effects of chemotherapy depend mainly on the drugs the patient
receives.
Radiation therapy
Radiation therapy (also called radiotherapy) is the use of high-energy rays to
damage cancer cells and stop them from growing. When used, it is generally in
combination with surgery and chemotherapy, or used only with chemotherapy in cases
where the individual is unable to undergo surgery. Radiation therapy may be used to
relieve pain or blockage by shrinking the tumor for palliation of incurable disease
Multimodality therapy
While previous studies of multimodality therapy (combinations of surgery,
chemotherapy and radiation therapy) gave mixed results, the Intergroup 0116 (SWOG
9008) study showed a survival benefit to the combination of chemotherapy and radiation
7
therapy in patients with nonmetastatic, completely resected gastric cancer. Patients

were randomized after surgery to the standard group of observation alone, or the study
arm of combination chemotherapy and radiation therapy. Those in the study arm
receiving chemotherapy and radiation therapy survived on average 36 months;
compared to 27 months with observation.
Specific Treatment for Gastric Lymphoma
Lymphomas of the stomach are primarily treated with chemotherapy

with CHOP with or without rituximab being a usual first choice.
CHOP – Cyclophosphamide, hydroxydaunorubicin (doxorubicin), Oncovin (vincristine)

and Prednisone/Prednisolone.
This regimen can also be combined with the monoclonal antibody rituximab if the
lymphoma is of B cell origin; this combination is called R-CHOP or CHOP-R. Typically,
courses are administered at an interval of two or three weeks (CHOP-14 and CHOP-21
respectively). A staging CT scan is generally performed after three cycles to assess
whether the disease is responding to treatment.
Antibiotic treatment to eradicate H. pylori is indicated as first line therapy

for MALT lymphomas. About 60% of MALT lymphomas completely regress with
eradication therapy. Second line therapy for MALT lymphomas is usually chemotherapy
with a single agent, and complete response rates of greater than 70% have gain been
reported.
Subtotal gastrectomy, with post-operative chemotherapy is undertaken in
refractory cases, or in the setting of complications, including gastric outlet obstruction.
Treatment of H.Pylori infections with combinations of antibiotics and acid
inhibitors successfully limits the infection and eventually eradicates the bacteria from the
stomach.
8
Health
Teaching
9
Patient and Family Health Teaching
 Advise patient to comply medications as prescribed by the

physician.
 Advise the family to maintain a clean and safe environment.
 Do tepid sponge bath if fever occurs.
 Encourage proper hygiene of the patient and family.
 Keep the area around the jejunostomy tube clean and dry.
 If the surgical wound(jejunostomy) has already healed, do not keep
the site covered with gauze to avoid moisture and skin breakdown.
 Proper preparation and storage of food
 Fruits and vegetables in everyday meal
 Avoid too much alcoholic foods
 Limit salty foods and foods with preservatives
0
Nursing Care
Plan
1
2
ASSESSMENT DIAGNOSIS PLANNING INTERVENTION EVALUATION

ACTION RATIONALE
Subjective: Imbalanced After the medical  Assess Provides the At the end of the
“Hindi na ako Nutrition: less and nursing nutritional opportunity to medical and
makakain kaya than body management, the status observe nursing
namayat ako ng requirements r/t patient will be able continually, deviations from interventions, the
ganito” as dysphagia and to acquire adequate during daily normal patient patient will be able
verbalized. surgical nutrition nursing care, baseline, and to regain
procedure noting energy influences choice appropriate weight.
Objective: secondary to level; of interventions.
 Thin gastric condition of
extremities carcinoma skin, nails,
 Weakness hair, oral
 Diet: NPO cavity
 With an IVF  Weigh daily  Establishes
of D5NSS baseline, aids
 With in monitoring
jejunostomy effectiveness
tube of therapeutic
 Decreased regimen, and
subcutaneous alerts nurse to
fat inappropriate
 Poor muscle trends in
tone weight
loss/gain.
 Document  Identifies
parenteral imbalance
intake and between
calorie counts estimated
as appropriate nutritional
requirements
and actual
intake.
3
 Administer  Nutrition
nutritional support
solutions at prescriptions
prescribed are based on
rate. Adjust individually
rate to deliver estimated
prescribed caloric and
hourly intake protein
requirements.
A consistent
rate of nutrient
administration
ensures
proper
utilization with
fewer side
effects, such
as
hyperglycemia
or dumping
syndrome
 Schedule  Conserves
activities with energy/reduce
adequate rest s calorie
periods. needs.
Promote
relaxation
techniques.
 Administer  Vitamins are
medications given for
as identified
indicated(vita deficiencies.
min K)
4
ASSESSMENT DIAGNOSIS PLANNING INTERVENTION EVALUATION

ACTION RATIONALE
Subjective: Risk for After 8 hours of  Stress/model  Reduces risk of At the end of the
“Nanghihina pa Infection r/t nursing proper cross- nursing
rin ako” as malnutrition intervention, the handwashing contamination intervention, the
verbalized. and surgically patient will remain technique. patient will show no
 Maintain sterile  Prevents entry
placed free of signs of signs of
technique for of bacteria,
Objective: jejunostomy infections and other invasive reducing risk of
infections/complicat
 Weak in tube complications. procedures. nosocomial ions as evidenced
appearance Provide routine infections. by normal vital
 Thin site/wound and signs.
extremities perineal care
 Frequently  Encourage  Limits stasis of
asleep frequent body fluids,
 Poor muscle position promotes
tone changes optimal
functioning of
organ systems,
GI tract.
 Screen  Reduces risk of

visitors/care transmission
providers for viruses that are
infectious difficult to treat.
processes,
especially URI.
 Assess vital  A rise in pulse
signs and
temperature
may provide
warning of
infectious
process unless
5
patient’s
immune system
is too
compromised to
respond.
 Keep the  Protects

surgical site catheter
clean and dry. insertion sites
Maintain a from potential
sterile occlusive sources of
dressing over contamination
catheter
insertion site.
 Aseptically  Prevents
prepare potential
parenteral contamination
solutions
 Administer  May be given
antibiotics as prophylactically
indicated. or for
(cefuroxime) specifically
identified
organism.
 Keep linen dry  Moist and
and free of wrinkles on the
wrinkles linen provides
susceptibility for
bacterial
growth.
6
Drug Study
7
VITAMIN K
Phytonadione
Mode Of Nursing
Classification Dosage Indication Contraindication Adverse Effects
Action Responsibility
.
Vitamin/ 1amp IVP Promotes ➣Hypoprothrom ● Contraindicated Hyperbilirubinemia >Observe for
Supplement then hepatic binemia caused in hypersensitivity (in infants); with allergic reactions:
q6°x3dos synthesis of by to drug or its parenteral flushed skin,
es active anticoagulant components. administration— nausea, rash, and
prothrombin, therapy (Life-threatening pain, swelling, itching. Medical
proconvertin, ➣Hypoprothrom reactions tenderness at attention should
plasma binemia resembling injection site; itchy be sought if any of
thromboplast secondary to hypersensitivity rash after repeated these symptoms
in other causes or anaphylaxis injections; transient occur.
component, have occurred flushing sensations; >Use cautiously in
and Stuart during and peculiar taste; certain types of
factor immediately after anaphylactoid liver problems.
I.V. reactions
injection.)
● Use cautiously
in pregnant or
breastfeeding
patients, children,
and neonates
(if product
contains benzyl
alcohol).
● Avoid P.O. use
in disorders that
may
prevent adequate
8
absorption.
PARACETAMOL
Acetaminophen
Mode Of Nursing
Analgesic, 300mg IV Unclear. Pain ➣Mild to ● Hypersensitivity Hematologic:  Observe for
antipyretic q4°PRN relief may moderate pain to drug thrombocytopenia, acute toxicity
ANST(-) result from caused by hemolytic and overdose.
inhibition headache,mus anemia, ● Caution
of cle ache, neutropenia, parents or other
prostaglandin backache, leukopenia, caregivers
synthesis in minor pancytopenia not to give
CNS, arthritis, Hepatic: jaundice, acetaminophen
with common cold, hepatotoxicity to children
subsequent toothache, Metabolic: younger than
blockage of or menstrual hypoglycemic coma age 2 without
9
pain cramps or Skin: rash, urticaria consulting

impulses. fever Other: prescriber first.
Fever hypersensitivity ● Tell patient,
reduction reactions (such parents, or other
may result as fever) caregivers not to
from use drug
vasodilation concurrently
and with other
increased acetaminophen-
peripheral containing
blood flow in products.
hypothalamus ● Advise patient,
, which parents, or other
dissipates caregivers to
heat and contact
lowers body prescriber if
temperature. fever or other
symptoms
persist despite
taking
recommended
amount of drug.
● Inform
patients with
chronic
alcoholism that
drug may
increase risk of
severe liver
damage.
● As
appropriate,
review all other
0
significant and
life-threatening
adverse
reactions and
interactions,
especially those
related to the
drugs, tests, and
behaviors
mentioned
above.
KETOROLAC
Ketorolac Tromethamine
Mode Of Nursing
1
Nonsteroidal 30mg Interferes ➣Moderately ● Hypersensitivity CNS: drowsiness, ● Be aware that

anti- SIVP with severe acute to drug, its headache, oral therapy is
inflammatory q6°ANST prostaglandi pain components, dizziness indicated
drug (NSAID, (-) n ➣Ocular itching aspirin, or other CV: hypertension only as
biosynthesis caused by NSAIDs EENT: tinnitus continuation of
by inhibiting seasonal ● Concurrent use GI: nausea, parenteral
cyclooxygen ➣Postoperative of aspirin, other vomiting, diarrhea, therapy.
ase pathway ocular NSAIDs, or constipation, ●Know that
of inflammation probenecid flatulence, parenteral therapy
arachidonic related to ● Peptic ulcer dyspepsia, shouldn’t exceed
acid cataract disease epigastric 20 doses in 5
metabolism; extraction ● GI bleeding or pain, stomatitis days.
also acts as ➣To reduce perforation Hematologic: ● For I.V. use,
potent ocular pain, ● Advanced renal thrombocytopenia dilute with normal
inhibitor of burning, or impairment, risk of Skin: rash, pruritus, saline
platelet stinging after renal failure diaphoresis solution, dextrose
aggregation corneal ● Increased risk of Other: excessive 5% in water,
refractive bleeding, thirst, edema, dextrose
surgery suspected injection 5% and normal
or confirmed site pain saline solution,
cerebrovascular Ringer’s
bleeding, solution, or
hemorrhagic lactated Ringer’s
diathesis, solution.
incomplete ● Administer
hemostasis single I.V. bolus
● Prophylactic use over 1 to
before major 2 minutes.
surgery, ● Inject I.M. dose
intraoperative use slowly and deeply.
when hemostasis ● Don’t give by
is critical epidural or
2
● Labor and intrathecal

delivery injection.
● Breastfeeding ● Monitor for
adverse reactions,
especially
prolonged
bleeding time and
CNS reactions.
● Check I.M.
injection site for
hematoma
and bleeding.
● Monitor fluid
intake and output.
CEFUROXIME
Cefuroxime Axetil
3
Mode Of Nursing
.
Second 750mg Interferes ➣Moderate to ● Hypersensitivity CNS: headache, ● Reconstitute
generation SIVP q8° with bacterial severe to cephalosporins hyperactivity, drug in vial with
cephalosporin ANST (-) cell-wall infections, or penicillins hypertonia, sterile
synthesis including ● Carnitine seizures water for injection.
and division those of skin, deficiency GI: nausea, ● Give by direct
by binding to bone, joints, vomiting, diarrhea, I.V. injection over
cell urinary abdominal 3 to
wall, causing or respiratory pain, dyspepsia, 5 minutes into
cell to die. tract, pseudomembrano large vein or
Active gynecologic us flowing
against infections colitis I.V. line.
gram- ➣Gonorrhea GU: hematuria, ● For intermittent
negative and ➣Bacterial vaginal candidiasis, I.V. infusion,
gram- meningitis renal dysfunction, reconstitute drug
positive ➣Otitis media acute renal failure with 100 ml of
bacteria, ➣Pharyngitis; Hematologic: dextrose 5% in
with tonsillitis hemolytic anemia, water or normal
expanded aplastic anemia, saline
activity hemorrhage solution;
against Hepatic: hepatic administer over 15
gram- dysfunction minutes
negative Metabolic: to 1 hour. For
bacteria. hyperglycemia continuous
Exhibits Skin: toxic infusion,
minimal epidermal give in 500 to
immunosupp necrolysis, 1,000 ml of
ressant erythema compatible
activity. multiforme, solution; infuse
Stevens-Johnson over 6 to 24
4
syndrome hours.
Other: allergic ● Inject I.M. doses
reaction, drug fever, deep into large
superinfection, muscle mass.
anaphylaxis ● Give oral form
with food.
● Be aware that
tablets and oral
suspension
are exchangeable
on a milligram-
for-milligram
basis.
5
EVALUATION
After 2 days of confinement, diagnostic procedure(CT scan) confirmed the
diagnosis of gastric lymphoma. An exploratory laparotomy and jejunostomy were done
to the patient and she was placed on NPO. 3 days after the surgery, weakness is still
present. The patient is still on NPO with parenteral nutrition provided. Laboratory result
shows high random blood sugar which may be due to prolonged infusion of parenteral
nutrition. It is also shown is laboratory results that there are decreased values of MCV,
MCH and MCHC which are indicative of anemia. Health teachings should be provided
to the patient as well as to the family since they are the primary care giver, in order to
prevent the development of further infections and complication and to prevent any other
family member from developing the same disease. And they should comply to the
therapeutic regimen as ordered. They should be able to show proper jejunostomy tube
care and if the patient shall be discharged, she should be referred to an infusion home
healthcare worker to make sure she would be set at home for proper nutrition.
BIBLIOGRAPHY
Book References:
Brunner and Suddarth,s Textbook of Medical and Surgical Nursing
Tenth Edition
Suzanne C. Smeltler, Brenda G. Bare
Essentials of Anatomy and Physiology

8th Edition
Elaine Marieb
Eternal Links:
www.nlm.nih.gov/medlineplus/ency/article/000223.htm
en.wikipedia.org/wiki/Stomach_cancer
emedicine.medscape.com/article/375384-overview
www.google.com
Others:
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1 Case Study: Gastric Carcinoma

First and foremost, I would like to express my sincerest

I also wish to express my deepest gratitude to my family for

I also thank my friends for their constant encouragement.

And to the patient and her relatives, I want to extend my

It is also my pleasure to thank the Dean of College of

Finally, I thank my most beloved teachers and those special

These can be symptoms of other problems such as a stomach virus, gastric

 Begin the evaluation with history taking and physical examination.

 Gastroscopic exam is the diagnostic method of choice. This involves insertion of

Abnormal tissue seen in a gastroscope examination will be biopsied by

A number of cutaneous conditions are associated with gastric cancer. A condition

SLEEP AND REST PATTERN

PAST HEALTH HISTORY

HISTORY OF PRESENT ILLNESS

Reason for seeking medical care: Loss of Appetite

Six months prior to admission, the patient noticed difficulty of

 Can move facial muscles at will

Eyes,Eyebrows and Eyelashes

Nose and Sinuses

Mouth and Oropharynx

THORAX AND LUNGS

Result Normal values Interpretation

Result Normal values Interpretation

Amorphous few few Normal

Result Normal values Interpretation

Eosinophils 01 1-5 Within normal range

Organs of the Alimentary Canal

The large intestine is much larger in

Accessory Digestive Organs

The liver has multiple functions, but its

Modifiable Factor: Helicobacter Pylori Non-Modifiable Factors:

Renders the mucosa more

upsets gastric acid secretory physiology to

Altered Gastric Secretion

Development of Gastric Ulcers and tissue injury

Persistent Immune Stimulation of Gastric lymphoid tissue

Helicobacter pylori infection is the cause of most stomach cancer. It is unclear

The following may help reduce your risk of gastric cancer:

As with any cancer, treatment is adapted to fit each person's individual

therapy in patients with nonmetastatic, completely resected gastric cancer. Patients

Specific Treatment for Gastric Lymphoma

Lymphomas of the stomach are primarily treated with chemotherapy

CHOP – Cyclophosphamide, hydroxydaunorubicin (doxorubicin), Oncovin (vincristine)

Antibiotic treatment to eradicate H. pylori is indicated as first line therapy

Patient and Family Health Teaching

 Advise patient to comply medications as prescribed by the

ASSESSMENT DIAGNOSIS PLANNING INTERVENTION EVALUATION

ASSESSMENT DIAGNOSIS PLANNING INTERVENTION EVALUATION

 Screen  Reduces risk of

 Keep the  Protects

pain cramps or Skin: rash, urticaria consulting

Nonsteroidal 30mg Interferes ➣Moderately ● Hypersensitivity CNS: drowsiness, ● Be aware that

● Labor and intrathecal

Essentials of Anatomy and Physiology

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