Submitted to

Mr.P.Yonatansir

Associate professer

Jg college of nursing

Ahmedabad Submitted by

Mrs Heena Mehta

S.Y.M.Sc Nursing

Jg college of nursing

Ahmedabad

Sub-Medical Surgical Nursing

Topic- Basal cell carcinoma of face

Submitted to-Mr.P.Yonatansir

Submitted by-Mrs Heena Mehta

Sr no content Page no1 Identification data2 History3 Physical examination4 Investigation5 Disease condition6 Definition7 Pathophysiology8 Management9 Nursing diagnosis10 Health teaching11 Bibliography

IDENTIFICATION DATA

PATIENT’S NAME: Jivatiben Bhojabhai Gajjar

Indoor. no: F 56854

AGE:64 years

SEX:Female

DATE OF ADMISSION`: 12-1-2012

DR’S UNIT: Unit-2 Dr.prakash patel

WARD: cancer female medical ward

MARRITAL STATUS: married

RELIGION: Hindu

EDUCATION: Illiterate .

OCCUPATION: House wife

ADDRESS: Jetpur,Rajkot

DIAGNOSIS: Basal cell carcinoma of the face

HEIGHT: 146Cm

WEIGHT: 57Kg

PRESENTING COMPLAINS :

Patient having complained of following:

-Fever

-Itching on face

-Black ulcer on the face

-Dryness of face skin

-Indigesion

-Weakness

PRESENT HISTORY:

Jivatiben has complain of the dryness of the face skin, itching of the face , black ulcer on the face, loss of apitite and weakness since last 8 month so she has to gone for treatment at private hospital in Jetpur (Rajkot) but symptoms not relieve itching constant occure than she refer to the civil hospital for medication.

PAST HISTORY:

PAST MEDICAL HISTORY:

Upto 64 year she has lot off time taken medication for minor disease but not need any hospitalization ,symptomatic medication taken for three to five day and symptoms relieve but last 8 month she was suffering from the skin disease and symptoms not relieve thus refer civil hospital and finally after total investigation she diagnose BASAL CELL CARCINOMA OF THE FACE and admit in the civil hospital for treatment.

PAST SURGICAL HISTORY:

No any surgical treatment needed Jivatiben, No any surgery done to the Jivatiben.

DIET HISTORY:

Jivatiben taken normal diet in her life. She has a farm so her husband grow normaly all types of vegetables in his farm .

PERSONAL HISTORY:

Diet : vegetarian & taking all type of small amount diet Appetite : Decreased Sleep :disturb Micturation : No burning micturation Bowel habit: Abnormal habits Smoking : No Alcohol : No Drugs : No Tobacco : No No any other habits

FAMILY HISTORY:

In her family no any family members have history of any Hypertension, Diabetes mellitus, Ischemic heart disease, Epilepsy, Asthma, Storks, Arthritis, Cancer or any other disease. Her father suffering from the tuberculosis and expired with this disease.

Sr.No.

Name of Family Members

Age in Year

Relationship

With patientEducation Occupation

1 Bhoja bhai Budhabhai Gajjar

7oYrs. Husband Illiterated Farmer

2 Jivatiben Gajjar 64Yrs Patient Illiterated Housewife

3 Jentibhai Gajjar 46Yrs Son 8th pass Farmer

4 Nanduben Gajjar 40Yrs Son’s wife 7th pass Housewife

5 Ramesh Gajjar 20Yrs Grand son 12th pass Farmer

6 Neeta Gajjar 15 Yrs Grand daughter

10th -

7 Rasik Gajjar 25 son B.Com -

8 Nanji Gajjar 20 son B.Com -

SOCIOECONOMIC HISTORY:

In Jivatiben’s house , her husband and elderson as a farmer so they work in farm and grow seasional vegetables and cereals for family and for sale so her income is not fix sometime her family earn more money and some times her family earn less money.

PHYSICAL EXAMINATION:

VITAL SIGN

Date Temp ( F)

Pulse (/min)

Respiration(/min) BP (mm of Hg)

16-07-2012

100 F 100/min 20/min 118/74

17-07-2012

99 F 126/min 24 min 122/64

18-07-2012

99 F 120/min 26 min 114/78

19-07-2012

98.6F 116/min 20 min 120/74

GENERAL OBSERVATION:

Sensorium: She is conscious and well oriented Foul body odour: no any bad odour from her body Foul breath : no Posture : normal Hair: Brown hair, clean no any dandruff.

GENERAL APPERANCE:

Body image: normal Health: Unhealthy Activity: less active

MENTAL STATUS:

Consciousness: conscious

Look: weakness, fatigue due to her disease.

Posture

Body curves: normal Movement: Full movement(if given deep pain than small reflection was done by

patient)

Height: 146cm Weight: 67kg

SKIN CONDITION:

Color: pallor Texture: Rough skin Temperature: warm Lesions: no lesions present

HEAD & FACE:

Scalp: clean Face: pale, fatigue, fear, anxiety

EYES:

Eyebrow: normal Eye lashes: no infection, not open by patient Eyelids: no any injury or oedema is present Eye balls: not sunken Conjunctiva: pale Sclera: no jaundiced Pupils: constricted Vision: react to light

EAR:

External ear: no discharge present Hearing: normal

NOSE:

External nares: Redness present Nostrils: normal. keeping face mask for proper oxygenation

MOUTH & PHARYNX: Lips: dry odour of the mouth: not present Teeth: normal Mucus membrane: dry Tongue: pale and moist

NECK:

Lymph node: Not palpable Thyroid gland: normal Range of motion: flexion, extension and rotation when done by someone, patient able

to done by own self.

CHEST:

Thorax: expansion Breath sound: No any sound heard Heart: normal

ABDOMEN:

Observation: no skin rashes and scar Auscultation: reduced bowel sound Palpation: no tenderness present

Percussion: not presence of gas, fluid or masses

EXTREMITIES:

Lower extremities: fully movements of lower extremities. mild oedema present Upper extremities: can move both hands but mild oedema is present

Genital and rectum:

No enlarged inguinal lymph nodes, No hemorrhoids, no enlargement of prostate glands.

Bladder & Bowel Pattern: Abnormal.

INVESTIGATION:

Serum Biochemistry test:

Investigation In patient Normal value

HemoglobinRBCUREAWBCS.creat.SGPTS. phosphateS.Billirubin

BLOOD CHEMISTERYFASTINGCHOLESTROL

12 % gm%100 mg/dl24mg/dl9,200/cumm0.59mg/dl36U/L 108 U/L0.7mg/dl

90.0mg/ dl174 mg/dl

14 – 17 gm %.153mg/ml15-45mg/dl4000-11000/cumm0.7-1.5mg/dl0-55U/L<50-150U/L0.2-1.2mg/dl

70-110mg/dl>240.0mg/dl

Serum Electrolytes:

Investigation In patient Normal valueS. Na+ 144.3 meq/L 135-145meq/L

S.K+Chloride

4.62 meq/L105

3.5-5.5 meq/L97-108

X-RAY CHEST:

Olcg in bothlungs

ECG: wnl

MEDICATION

CHEMOTHERAPY GIVEN AFTER SURGERY

-Injection 5FU and cyclophosphamide regimen every 3week for three cycle.

-Injection amikasine 500gm i/v 12hourly.

-Injection voveran 1 ampoule i/v 12hourly.

- Injection Ondensten 1 ampoule i/v sos

- Tablet-Rantac 150 mg 1 bd.

-Tablet- MV/BC 1 bd

Maintain intake and output chart daily Contineus observation of the patient on monitor for any abnormal symptoms. TPR chart 1 hourly Monitoring continuously for blood pressure, respiration rate,

pulse, and for oxygen saturation. Care taken of catheter daily Care taken of all tubes which are inserted Watched for respiratory failure . Changed the dressing and adhesive tap at the site of intracath.

DISEASE CONDITION

ANATOMY AND PHYSIOLOGY OF SKIN-

The skin is the largest organ in the body, comprising about 15% of the body weight. The total skin surface of an adult ranges from 12 to 20 square feet. In terms of chemical composition, the skin is about 70% water, 25% protein and 2% lipids. The remainder includes trace minerals, nucleic acids, glycosoaminoglycans, proteoglycans and numerous other chemicals.

The skin consists of three main layers: epidermis, dermis and subcaneous tissue.

The Epidermis

The epidermis is the topmost layer of the skin. It is the first barrier between you and the outside world. The epidermis consists of three types of cells keratinocytes, melanocytes and Langerhans cells. Keratinocytes, the cells that make the protien keratin, are the predominant type of cells in the epidermis. The total thinkness of the epidermis is usually about 0.5 - 1 mm. At the lowermost portion of the epidermis are immature, rapidly dividing keratinocytes. As they mature, keratinocytes lose water, flatten out and move upward. Eventually, at the end of their life cylce, they reach the uppermost layer of the epidermis called stratum corneum. Stratum corneum consists mainly of dead keratinocytes, hardened proteins (keratins) and lipids, forming a protective crust. Dead cells from stratum corneum continuously slough off and are replaced by new ones coming from below. The skin completely renews itself every 3 - 5 weeks. Most mild peels work by partly removing the stratum corneum and thus speeding up skin renewal.

Another significant group of cell in the epidermis are melanocytes, the cells producing melanin, the pigment responsible for skin tone and color. Finally, Langerhans cells are essentially a forepost of the immune system in the epidermis. They prevent unwanted foreingn substances from penetrating the skin.

The condition of epdermis determines how "fresh" your skin looks and also how well your skin absorbs and holds moisture. Wrinkles, however, are formed in lower layers.

The Dermis

The dermis is the middle layer of the skin located between the epidermis and subcutaneous tissue. It is the thickest of the skin layers and comprises a tight, sturdy mesh of collagen and

elastrin fibers. Both collagen and elastin are critically important skin proteins: collagen is responsible for the structural support and elastin for the resilience of the skin. The key type of cells in the dermis is fibroblasts, which synthesize collagen, elastin and other structural molecules. The proper function of fibroblasts is highly important for overall skin health.

The dermis also contains capillaries (tiny blood vessels) and lymph nodes (depots of immune cells). The former are important for oxygenating and nourishing the skin, and the latter -- for protecting it from invading microorganisms.

Finally, the dermis contains sebacious glands, sweat glands, hair follicles as well as a relatively small number of nerve and muscle sells. Sebacious glands, located around hair follicles, are of particular importance for skin health as they produce sebum, an oily protective substance that lubricates and waterproofs the skin and hair. When sebacious gland produce too little sebum, as is common in older people, the skin becomes excessively dry and more prone to wrinkling. Conversely, overproduction or improper composition of sebum, as is common in adolescents, often leads to acne.

The dermis is the layer responsible for the skin's structural integrity, elasticity and resilience. Wrinkles arise and develop in the dermis. Therefore, an anti-wrinkle treatement has a chance to succeed only if it can reach as deep as the dermis. Typical collagen and elastin creams, for example, never reach the dermis because collagen and elastin molecules are too large to penetrate the epidermis. Hence, contrary to what some manufacturers of such creams might imply, these creams have little effect on skin wrinkles.

Subcutaneous tissue

Subcutanous (hypodermis) tissue is the innermost layer of the skin located under the dermis and consisting mainly of fat. The predominant type of cells in the subcutaneous tissue is adipocytes or fat cells. Subcutaneous fat acts as a shock absorber and heat insulator, protecting underlying tissues from cold and mechanical trauma.  Interestingly, most mammals lack subcutaneous tissue because their fur serves as a shock absorber and heat insulator. Sweat glands and minute muscles attached to hair follicles originate in subcutaneous tissue.

The loss of subcutaneous tissue, often occurring with age, leads to facial sag and accentuates wrinkles. A common procedure performed by dermatologists to counteract this process is to inject fat (collected elsewhere in the body) under the wrinkles on the face.

DEFINITION: Basal cell carcinoma is the most common form of cancer worldwide and accounts for about 80% of all cases of skin cancer.

CAUSES:

In Book In PatientRadiation expose, UV Rays noGene Maturations May be

Arsenic exposure through ingestion no

Immunosuppression May be

Xeroderma pigmentosum May be

Epidermodysplastic verruciformis no

Nevoid basal cell carcinoma syndrome No

Bazex syndrome No

Previous nonmelanoma skin cancer no

Rombo syndrome No

Alcohol consumption no

Types of basal cell carcinoma of the skin

In Book In My Patient

Nodular: About 60% of BCCs are nodular. They start out as flat, well-defined lesions, then often become small bumps, which eventually collapse in the middle, leaving a raised ring on the border. Most nodular BCCs are on the face and so can be disfiguring if not treated promptly.

Pigmented: Pigmented BCCs are similar to the nodular type, but they can have brown or black spots in them. They can be confused with some types of melanoma.

Fibrosing or Sclerotic: These BCCs are usually found on the face and look similar to scars. They are usually firm, ill-defined at the border, flat or slightly depressed, yellowish in color, and the surface tends to be smooth and shiny.

There is small nodes seen over the face.

There is Black pigmentation seen over nodes

Superficial: This type comprises about 15% of BCCs. They spread outward from a red, well-defined, scaly patch, most commonly found on the trunk and limbs. They are easily confused with psoriasis or eczema.

Fibroepithelioma of Pinkus: This is a rare type of BCC. It tends to be a smooth, elevated, small nodule found on the back, extremities, groin, or sole of the foot. As those are not sun-exposed areas, this disease is probably not sun-related.

PATHOPHYSIOLOGY:

Over exposure to sun leads to the formation of thymine dimers, a form of DNA damage.

cumulative DNA damage leading to mutations.

Apart from the mutagenesis, over exposure to sunlight depresses the local immune system,

Basal-cell carcinoma also develops as a result of Basal-Cell Nevus Syndrome,

Developed tumors of the jaw, palmar or plantar (sole of the foot) pits, calcification of the falx cerebri (in the center line of the brain) and rib abnormalities.

which inhibits the hedgehog signaling pathway.

A mutation in the SMO gene, which is also on the hedgehog pathway, also causes basal-cell carcinoma

CLINICAL MENIFESTATION:

In Book In Patient

skin bump or growth that is:

Pearly or waxy White or light pink Flesh-colored or brown

Present

A skin sore that bleeds easily Present A sore that does not heal Present Oozing or crusting spots in a sore Not PresentAppearance of a scar-like sore without having injured the area

Present

Irregular blood vessels in or around the spot

Not Present

A sore with a depressed (sunken) area in the middle

Not Present

ASSESSMENT & DIAGNOSTIC FINDINGS:

IN BOOK IN PATIENT- Taking a thorough history

including family history- Done

- Physical examination (note BP & weight)

- Done

- Laboratory work (cholesterol levels, glucose )

- Done

skin biopsy Shave biopsy uses a thin surgical

blade to shave off the top layers of skin. This is the most common method for diagnosing BCC.

Punch biopsy uses a round, cookie cutter-like tool. It is used to take a deeper skin sample.

- Done

MANAGEMENT:

Curettage and electrodessication Surgical excision (removal) Mohs surgery (also known as "micrographic surgery"), especially if the lesion is on the

face, is recurrent, has a diameter of greater than 2 cm, or is the sclerotic type Topical creams such as imiquimod is FDA-approved for the treatment of superficial BCCs

not on the face, although studies have shown it can be effective against nodular BCC as well

ExcisionSimple surgical excision (removal) is used to treat both primary and recurrent tumors. The procedure involves surgically removing the tumor and a certain amount of normal-appearing skin surrounding it (the "margin"): For basal cell and squamous cell carcinomas, margins are often 2 to 4 mm. The cure rates following excision are 95% and 92% for primary BCC and SCC, respectively, and are dependent on the site, size, and pattern of the tumor. Excision may be performed in the outpatient or inpatient setting depending on the extent of the cancer.

Topical CreamsSince its approval in 2004, the immune systemactivator imiquimod (also known by the brand nameAldara) has been a commonly prescribed topical (skin only) cream for small superficial and nodular basal cell carcinomas, as well as a pre-cancerous condition called actinic keratosis. It is spread on the lesion five times per week, usually for six weeks, and completely clears the skin in about 88% of patients or more, depending on the exact type of cancer. Another cream for superficial BCC is 5-flourouracil (Carac or Efudex), a chemotherapy drug that is also used intravenously. These treatments usually don't leave any scars, but they can cause considerable pain and swelling as they work. Several other creams are being tested now, including ingenol mebutate(PEP005), which is derived from a plant called the "petty spurge."

Curettage and ElectrodesiccationCurettage and electrodesiccation is a simple, quick and effective method for destroying small basal cell and squamous cell carcinomas. After scraping away the growth with a long spoon-like instrument called a curette, the physician uses a mild electric current to destroy any remaining abnormal cells. This scraping and cauterizing process is typically repeated three times, and the wound tends to heal without stitches. It is best for primary, not recurrent, lesions. The cure rates depend on the site: high-risk locations (nose, ear, chin, mouth) have a recurrence rate of 4% to 18%, depending on the tumor size. Recurrence rates decrease to 3% for tumors at low-risk sites of the trunk and extremities. Overall, the 5-year cure rates for primary BCC and SCC treated with C and E are 92% and 96%, respectively.

Mohs SurgeryThe Mohs procedure (also known as Mohs micrographic surgery or margin controlled excision) is an advanced technique developed in the 1940s by Dr. Frederic E. Mohs for removing lesions due to basal or squamous cell carcinoma. It involves removing thin sections of the skin growth, layer by layer. Each layer is then examined under the microscope, and removal of layers continues until no cancerous cells remain. It has the highest cure rate of any skin cancer treatment and doesn't cause as much scarring as other methods. It is especially useful for treating recurring skin cancer, larger tumors, tumors on the ear, eyelid, nose, lip, or hand, tumors in sites prone to recurrence, and the sclerotic subtype of basal cell carcinoma. It is the "gold standard" treatment: The 5-year recurrence rate is 1% for BCC and 3% for SCC. However, it is more costly, time-consuming, and labor-intensive than other methods.

MEDICAL MANAGEMENT:

- Chemotherapy in four cycle with Adreamycine and cyclophosphemide.

- Analgesics - Antibiotics

NURSING MANAGEMENT:

- Identify at risk patients, & teach lifestyle modifications to prevent development any complication.

- Teach patient to control cholesterol levels through dietary reduction of cholesterol intake, exercise, smoking cessation.

- Note & report findings from history, physical examination, & laboratory results that indicate hypertension or diabetes, & teach to control blood pressure by taking treatment in the nearest hospital.

NURSING DIAGNOSIS:

1. Risk for infection related to decrease immune system.2. Altered body temperature due to presence of infection.3. Imbalance nutritional level less than body requirement related to loss of appetite.4. Activity intolerance related to disease.

5 Impaired body image due disease.

6 Altered self image and confidence due to fegure.

HEALTH TEACHING:

Explain patient’s relatives about discharge planning.Give advice about regular medication as per timing.Advice given about good nutritive diet.Advice given for prevention of infection management.

Prevention

The best way to prevent skin cancer is to reduce your exposure to sunlight. Ultraviolet light is most intense at midday, so try to avoid sun exposure during these hours. Protect the skin by wearing hats, long-sleeved shirts, long skirts, or pants.

Always use sunscreen:

Apply high-quality sunscreens with SPF (sun protection factor) ratings of at least 15. Look for sunscreens that block both UVA and UVB light. Apply sunscreen at least 30 minutes before going outside, and reapply it frequently. Use sunscreen in winter, too.

Possible Complications

Untreated, basal cell cancer can spread to nearby tissues or structures, causing damage. This is most worrisome around the nose, eyes, and ears.

Explain about follow up care.

BIBLIOGRAPHY:

1. Bennette and Plum; “TEXTBOOK OF MEDITION ; 10thedition, 1996; W.B. Saunders Company, New York : 1996. PP :

2. Black J.M; “MEDICAL SURGICAL NURSING; 5th edition, 1999 ; W.B. Saunders Company, Philadelphia. PP:

3. Brunners & Suddarth’s; “TEXT BOOK OF MEDICAL SURGICAL NURSING VOL-_1”;10th edition, 2004; Elsevier Publishers, New Delhi, India. PP:

4. B T Basavanthappa;”TEXT BOOK OF NURSING THEORIES”,Jaypee brothers Medical Publishers ,New Delhi.

PP: 40-WEBSITES:

- http://www.wikipedia.com .

- http://www.patho.skindisease.org/.com.in

- http://www.google.com.- http://www.medicine.com .