Case Presentation Template- ACoN (3).pptx

cervical cancer

1. 1   Army CoN Cervical Cancer Prevention, detection, and awareness Capacity building ECHO for Nurses in Punjab CASE PRESENTATION PRESENTER’S NAME - Ms. Khushnasib

2. Patient Information Name: Mrs. Rahela Age : 55 yrs Gender: Female Date of admission: 27 – 12 – 2023 Date of discharge: 30 -12 – 2023 Chief Complaints: o Post coital bleeding for 1 year Foul smelling per vaginal discharge for 6 months Per vaginal bleeding on straining for 4 months Back pain for 4 months

3. Diagnosis: Carcinoma of cervix stage IV a History of Present Illness – According to the statement of the patient she was reasonably well 1 year back then she suddenly developed post coital bleeding that was excessive in amount and bright red in color. She also gives history of foul smelling dirty brown colored per vaginal discharge for 6 months that was thick in consistency but not associated with itching. She further mentioned about per-vaginal bleeding on straining occasionally for 4 months. She has continuous low back pain for 4 months which was insidious in onset with no radiation and no aggravating and reliving factor. On query she also complains of anorexia and weight loss. Her bladder habit is normal but she is constipated.

4. Past History of medical illness (if any): She has no significant past medical, past surgical and past gynecological history . Social History (Life style History- Tobacco use, sexual activity, contrapception methods and any other pertitnet factors ) - She took betel nut and tobacco for 30 years Any H/O Surgery/BT/IV Drug use/Tattooing: nil Comorbidities (if any): nil Family history (Any family history of cancer ): No significant family history given

5. Physical Examination: Vital Signs: Temperature : Normally around 98.6°F (37°C), but fever can occur due to infection or inflammation related to cancer. Pulse Rate : Normal resting heart rate is between 60 to 100 beats per minute. Cancer can sometimes cause anemia or affect the heart directly, altering pulse rate. Respiratory Rate : Typically 12 to 20 breaths per minute. Cancer progression or metastasis can affect respiratory function. Blood Pressure : Normal range is typically around 120/80 mmHg. Cancer and its treatments can sometimes lead to fluctuations in blood pressure.

6. General Appearance : Fatigue : Patients with cervical cancer often experience fatigue, which can be debilitating and affect their overall appearance and energy levels. Weight Changes : Depending on the stage and treatment of cervical cancer, patients may experience weight loss or gain. Unintended weight loss can be a concerning symptom. Pallor : Anemia is common in cancer patients, including those with cervical cancer. This can lead to a paler complexion. Pain : Patients may exhibit signs of discomfort or pain, especially if the cancer has progressed and is causing pressure on nearby structures or nerves. Emotional State : Dealing with a cancer diagnosis and its treatments can affect a patient's emotional well-being. They may appear anxious, withdrawn, or emotionally fatigued. Physical Signs : Depending on the extent of the cancer, there may be visible signs such as abdominal swelling or enlargement due to tumors, or signs of metastasis to other organs. Gait and Mobility : Advanced stages of cervical cancer may impact a patient's ability to move comfortably or their gait due to pain or physical limitations.

7. Systemic Examination: General Inspection : Begin by observing the patient's general appearance, noting any signs of distress, fatigue, pallor, or discomfort. Assess their demeanor, level of alertness, and emotional state. Vital Signs : Measure and record vital signs including temperature, pulse rate, respiratory rate, and blood pressure. Note any abnormalities that could indicate infection, anemia, or cardiovascular issues. Head and Neck Examination : Inspect the neck for lymph node enlargement, particularly in the cervical region. Palpate lymph nodes for size, tenderness, and mobility, as enlarged nodes may indicate metastasis. Respiratory System : Auscultate lung fields to detect any abnormal breath sounds or signs of metastasis to the lungs. Assess respiratory effort and note any complaints of cough or shortness of breath.

8. Cardiovascular System : Auscultate heart sounds and assess for any murmurs or irregularities, as cancer and its treatments can affect cardiovascular function. Evaluate peripheral pulses and assess for signs of fluid retention or edema. Abdominal Examination : Palpate the abdomen for any masses, tenderness, or organ enlargement. Cervical cancer can spread locally to affect nearby structures like the bladder or rectum. Assess liver and spleen size and tenderness. Pelvic Examination : Perform a pelvic exam to assess the cervix for tumors, ulcerations, or abnormal growths. Palpate the pelvis for any masses or tenderness and assess for signs of local invasion or metastasis to adjacent pelvic organs. Neurological Examination : Evaluate cranial nerves, motor strength, sensation, and reflexes to detect any signs of neurological involvement, especially if there is metastasis to the brain or spinal cord.

9. Diagnostic Evaluation : Pap Smear Results : Interpretation: Specimen Adequacy: Satisfactory for evaluation. Interpretation: Atypical squamous cells of undetermined significance (ASC-US) cannot exclude high-grade squamous intraepithelial lesion (ASC-H). Comments (if applicable): HPV Test: Positive for high-risk HPV (e.g., HPV 16). Recommendation: Colposcopy and biopsy are recommended due to the presence of atypical cells and positive HPV result. Impression: Findings Suggestive of: High-grade squamous intraepithelial lesion (HSIL) or cervical intraepithelial neoplasia (CIN) 2/3. Clinical Correlation: Consideration of cervical biopsy for definitive diagnosis and further management.

10. Biopsy Results: [Summarize the findings of any cervical biopsy, including histopathological analysis and staging information if available.] Histopathology Report: Specimen: Cervical biopsy Macroscopic Description: A fragment of cervix measuring 0.8 x 0.5 x 0.3 cm, pink-tan in color. Microscopic Description: Histologic Type: Squamous cell carcinoma Grade: Moderately differentiated Depth of Invasion: 5 mm into the cervical stroma

11. Margins: Positive at the ectocervical margin Lymphovascular Invasion: Present Perineural Invasion: Absent Immunohistochemistry (if performed): p16INK4a: Positive staining in tumor cells Conclusion: Diagnosis: Squamous cell carcinoma of the cervix Stage: III (according to FIGO staging) Comments: Recommend further staging workup including pelvic MRI and consultation with gynecologic oncology for consideration of definitive treatment options.

12. Imaging Studies : Pelvic MRI: Findings: Uterus: Normal size and shape. Cervix: Irregular thickening of the cervix with a nodular mass measuring 3.5 cm in diameter, involving the anterior and posterior cervix. Parametrial Tissues: Right parametrial extension of the tumor, involving up to 1 cm of the right parametrium . Lymph Nodes: Enlarged right internal iliac lymph node measuring 1.8 cm in short axis, highly suspicious for metastasis. Bladder and Rectum: No invasion identified. Other Organs: No distant metastases identified .

13. Chest CT Findings: Lungs: Clear, no evidence of pulmonary metastases. Pleura: No pleural effusion or nodularity. Other Thoracic Structures: Unremarkable. Conclusion: Stage: According to FIGO staging, the findings are suggestive of locally advanced cervical cancer (Stage IIB) with possible involvement of the right parametrium and suspicious lymph node metastasis. Recommendation: Referral to gynecologic oncology for consideration of definitive treatment options, including chemoradiotherapy and possible surgical resection based on multidisciplinary tumor board discussion.

14. Investigations(lab) Complete Blood Count (CBC): Hemoglobin: 11.5 g/ dL (Reference Range: 12.0-15.5 g/ dL ) Platelet Count: 220,000/mm³ (Reference Range: 150,000-400,000/mm³) White Blood Cell Count: 7,800/mm³ (Reference Range: 4,000-11,000/mm³) Differential: Within normal limits Renal Function Tests: Blood Urea Nitrogen (BUN): 12 mg/ dL (Reference Range: 7-20 mg/ dL ) Creatinine: 0.8 mg/ dL (Reference Range: 0.6-1.2 mg/ dL ) 3. Liver Function Tests: Total Bilirubin: 0.7 mg/ dL (Reference Range: 0.1-1.2 mg/ dL ) Alanine Aminotransferase (ALT): 18 U/L (Reference Range: 7-56 U/L) Aspartate Aminotransferase (AST): 22 U/L (Reference Range: 5-34 U/L) Alkaline Phosphatase: 65 U/L (Reference Range: 40-150 U/L)

15. Tumor Markers: Carcinoembryonic Antigen (CEA): 2.0 ng/mL (Reference Range: <5.0 ng/mL) Cancer Antigen 125 (CA-125): 28 U/mL (Reference Range: <35 U/mL) Squamous Cell Carcinoma Antigen (SCC-Ag): 3.5 ng/mL (Reference Range: <1.5 ng/mL) 5. Human Papillomavirus (HPV) Testing: Result: Positive for high-risk HPV types (e.g., HPV 16) Conclusion: Laboratory Findings: The CBC shows mild anemia, likely secondary to chronic disease. Renal and liver function tests are within normal limits. Tumor markers (CEA, CA-125, SCC-Ag) are within normal ranges except for SCC-Ag, which is mildly elevated, consistent with squamous cell carcinoma. HPV Testing: Positive for high-risk HPV, confirming the association with cervical cancer

16. Nursing Assessment Vitals Temperature: 37.0°C (98.6°F) Interpretation: Normal range for adults. Pulse: 82 beats per minute (bpm) Interpretation: Within normal range for adults (typically 60-100 bpm). Blood Pressure: 120/78 mmHg Interpretation: Normal blood pressure for adults (systolic <120 mmHg and diastolic <80 mmHg). Respiratory Rate: 16 breaths per minute Interpretation: Within normal range for adults (typically 12-20 breaths per minute).

17. Anthropometric measurements Height: 165 cm (5 feet 5 inches) Interpretation: Measurement of Jane Doe's standing height. Weight: 65 kg (143 lbs) Interpretation: Measurement of Jane Doe's body weight. Body Mass Index (BMI): Calculated as weight (kg) / [height (m)]^2 BMI Calculation: 65 kg / (1.65 m)^2 = 23.87 kg/m² Interpretation: BMI falls within the normal weight range (18.5-24.9 kg/m²). Additional Notes: weight has been stable over the past few months. No significant changes in height or BMI noted during recent assessments.

18. Systemic examination General Appearance: Rahela appears fatigued and mildly cachectic. Vital signs: Temperature 37.2°C, Pulse 90 bpm, Blood Pressure 110/70 mmHg, Respiratory Rate 20 breaths per minute. 2. Head and Neck: Head: Normocephalic , no palpable masses. Eyes: Conjunctivae pale, sclerae anicteric. Pupils equal and reactive to light. Ears: No external deformities, tympanic membranes intact bilaterally. Nose: Nasal mucosa dry, no discharge. Throat: Oropharynx clear, no masses or ulcerations .

19. Cardiovascular System: Heart: Regular rate and rhythm. S1 and S2 normal, no murmurs appreciated. Peripheral Pulses: Radial, brachial, femoral pulses palpable but slightly diminished bilaterally. 4. Respiratory System: Lungs: Diminished breath sounds at lung bases, no crackles or wheezes appreciated. 5. Abdomen: Inspect: Abdomen mildly distended, no visible masses. Palpate: Mild tenderness in the lower abdomen. Liver edge palpable 2 cm below the right costal margin, no splenomegaly appreciated.

20. . Musculoskeletal System: Mild muscle wasting noted in upper and lower extremities. 7. Neurological System: Mental Status: Alert but fatigued. Cranial Nerves: Intact bilaterally. Motor and Sensory: Normal strength and sensation in upper and lower extremities. 8. Skin: Pale and cool to touch, no rashes or lesions noted.

21. Lymphatic System: Palpable left supraclavicular lymph node, approximately 2 cm in diameter. No other palpable lymphadenopathy in cervical, axillary, or inguinal regions. Conclusion: This systemic examination of Jane Doe indicates findings consistent with advanced cervical cancer. The patient presents with signs of systemic illness including cachexia, fatigue, and mild abdominal tenderness. There are signs of potential metastatic involvement with the presence of a left supraclavicular lymph node. Vital signs show mild tachycardia and hypotension. These findings highlight the systemic impact of advanced cervical cancer and the need for comprehensive management, including palliative care and symptom control.

22. Treatment and Management: Diagnosis: Squamous cell carcinoma of the cervix, Stage IIIB (according to FIGO staging) 1. Multidisciplinary Team Discussion: Consultation with gynecologic oncologist, radiation oncologist, and medical oncologist. 2. Treatment Goals: Achieve local disease control. Manage symptoms and improve quality of life. Minimize treatment-related side effects . Treatment Modalities: A. Chemoradiotherapy : External Beam Radiation Therapy (EBRT): Total dose: 50.4 Gy in 28 fractions over 5.5 weeks. Target: Pelvic region including cervix and parametrial tissues. Brachytherapy: High-dose rate (HDR) brachytherapy boost after EBRT completion. Total dose: 24 Gy in 4 fractions over 2 weeks.

23. Chemotherapy: Concurrent cisplatin chemotherapy every 3 weeks during EBRT. Dose: 40 mg/m² IV on days 1 and 8 of each cycle. B. Surgical Evaluation: Consideration for radical hysterectomy and pelvic lymph node dissection after completion of chemoradiotherapy , depending on response to initial treatment and surgical candidacy. 4. Supportive Care: Pain Management: Regular assessment and use of analgesics as needed. Nutritional Support: Dietitian consultation for nutritional assessment and counseling. Psychosocial Support: Referral to oncology social worker or psychologist for emotional support and coping strategies.

24. Follow-Up Plan: Regular follow-up visits every 3 months initially, then every 6 months for clinical examination, imaging studies (e.g., pelvic MRI), and tumor marker assessment (e.g., SCC-Ag). Surveillance for late effects of treatment and potential recurrence. 6. Patient Education: Discuss treatment rationale, expected side effects, and self-care strategies. Provide resources for additional information and support groups. 7. Advanced Care Planning: Discussion of advanced directives and preferences for end-of-life care, if appropriate. Conclusion: This treatment plan outlines a comprehensive approach to managing Jane Doe's cervical cancer, incorporating chemoradiotherapy as the primary treatment modality, with consideration for surgical evaluation post-treatment. Supportive care and follow-up plans are essential components to optimize outcomes and ensure holistic patient care throughout the treatment journey.

25. Nursing Care Plan Diagnosis: Cervical cancer, Stage IIIB Nursing Diagnosis: Impaired Comfort related to pain secondary to cervical cancer and treatment interventions. Risk for Infection related to immunosuppression secondary to chemotherapy and radiation therapy. Risk for Impaired Skin Integrity related to radiation-induced dermatitis. Risk for Imbalanced Nutrition: Less than Body Requirements related to anorexia and treatment-related side effects. Anxiety related to diagnosis and treatment regimen . References:[Include any references or sources consulted in preparing the case presentation

26. Goals: Patient will report pain relief or pain control within acceptable limits (numeric pain rating scale ≤ 4) by [date]. Patient will remain free from signs and symptoms of infection throughout treatment. Patient's skin integrity will remain intact with no evidence of radiation-induced dermatitis. Patient will maintain or gain weight as appropriate for height and body frame during treatment. Patient will verbalize decreased anxiety and demonstrate effective coping strategies . Interventions: Pain Management: Assess pain using a numeric pain rating scale at regular intervals. Administer analgesics as prescribed, ensuring timely pain relief. Teach relaxation techniques and distraction methods to manage pain. Collaborate with the healthcare team to adjust pain management strategies as needed.

27. Infection Prevention: Monitor vital signs, especially temperature, for signs of infection. Educate patient and family on signs and symptoms of infection. Practice strict hand hygiene and encourage the patient to do the same. Monitor laboratory results (e.g., CBC, ANC) for signs of neutropenia and infection risk. Skin Care: Assess skin integrity daily, focusing on areas receiving radiation therapy. Provide gentle skin care using prescribed creams or lotions to prevent dryness and irritation. Educate patient on avoiding direct sunlight and wearing loose, soft clothing. Collaborate with radiation oncology team for recommendations on skin care products.

28. ns on skin care products. Nutritional Support: Assess nutritional status and dietary intake regularly. Encourage small, frequent meals and snacks high in protein and calories. Offer nutritional supplements or enteral feedings as prescribed. Refer to dietitian for individualized nutritional counseling and support. Anxiety Management: Use therapeutic communication to address patient's fears and concerns. Teach relaxation techniques such as deep breathing and guided imagery. Encourage participation in support groups or counseling services. Provide information about cervical cancer, treatment options, and expected outcomes to alleviate anxiety.

29. Evaluation: Pain Management: Rahela reports pain level consistently ≤ 4 on the numeric pain rating scale. She demonstrates use of relaxation techniques effectively. Infection Prevention: Rahela remains afebrile throughout treatment, with no signs or symptoms of infection observed. Skin Care: skin remains intact without signs of radiation-induced dermatitis. Nutritional Support: Rahela maintains weight or shows signs of weight gain, and nutritional markers (e.g., albumin levels) remain stable or improve. Anxiety Management: Rahela expresses decreased anxiety and utilizes coping strategies effectively. Collaborative Care: Collaborate with medical oncology, radiation oncology, and social services to ensure comprehensive care. Communicate regularly with the healthcare team to adjust the care plan based on patient's responses and needs. This nursing care plan aims to provide holistic care for Jane Doe, addressing her physical, emotional, and psychological needs throughout her treatment for cervical cancer. Regular assessment and communication are crucial to achieving the desired outcomes and promoting Jane's well-being during this challenging time.

30. Problem Statement A Pre experimental study to assess Knowledge , Practice and Barriers on Cervical Cancer Screening among Married Women in selected demographic area

31. Challenges faced in Managing the cervical cancer prevention programs need to include the consideration of individuals, health care providers and health system challenges. Addressing the low level of knowledge, negative attitudes, socio cultural challenges, Poor intersectional collaboration and coordination and intra-sectional management, financing and competency of health care providers are essential steps toward significantly reducing the burdens of cervical cancer.

32. Health Education Understanding Cervical Cancer: Explain what cervical cancer is, including its causes (HPV infection), risk factors (smoking, multiple sexual partners), and how it develops (precancerous changes in cervical cells). Provide information on the importance of regular cervical cancer screening (Pap smears, HPV testing) for early detection and treatment. HPV Vaccination: Educate about the HPV vaccine, its effectiveness in preventing HPV infections that can lead to cervical cancer, and the recommended age groups for vaccination (typically adolescents and young adults). Risk Reduction Strategies: Discuss lifestyle factors that can reduce the risk of cervical cancer, such as avoiding smoking, practicing safe sex (using condoms), and limiting the number of sexual partners. Symptoms and Signs: Teach about the signs and symptoms of cervical cancer, such as abnormal vaginal bleeding (between periods, after sex, or after menopause), pelvic pain, and unusual vaginal discharge. Screening Guidelines: Explain current guidelines for cervical cancer screening, including when to start screening, how often to get screened, and the types of tests available (Pap smear, HPV test).

33. Importance of Early Detection: Emphasize the benefits of early detection and treatment in improving outcomes and reducing mortality from cervical cancer. Follow-Up Care: Educate on the importance of follow-up care after abnormal screening results or diagnosis of cervical dysplasia (precancerous changes) or cervical cancer. Provide guidance on navigating the healthcare system for follow-up appointments, diagnostic tests, and treatment options. Cervical Cancer Prevention: Promote overall health practices that support cervical cancer prevention, such as maintaining a healthy diet, exercising regularly, and attending routine healthcare check-ups. Community and Public Health Initiatives: Discuss community-wide initiatives aimed at increasing awareness, promoting HPV vaccination uptake, and improving access to cervical cancer screening and treatment services. Addressing Myths and Misconceptions: Address common myths and misconceptions about cervical cancer and HPV, providing accurate information to dispel misinformation and promote informed decision-making.

34. References Bosch, F. X., & de Sanjosé , S. (2003). Chapter 1: Human papillomavirus and cervical cancer— Burden and assessment of causality. Journal of the National Cancer Institute Monographs, 2003 (31), 3-13. Crosbie , E. J., Einstein, M. H., Franceschi , S., & Kitchener, H. C. (2013). Human papillomavirus and cervical cancer. The Lancet, 382 (9895), 889-899. Ferlay , J., Soerjomataram , I., Ervik , M., Dikshit , R., Eser , S., Mathers , C., ... & Bray, F. (2013). GLOBOCAN 2012 v1.0, Cancer Incidence and Mortality Worldwide: IARC CancerBase No. 11. International Agency for Research on Cancer . Franco, E. L., & Rohan, T. E. (2011). Chapter 2: Epidemiology of cervical cancer. In P. L. Benedet , E. L. Franco, R. K. Miller, & M. G. Williams (Eds.), Colposcopy and Treatment of Cervical Intraepithelial Neoplasia: A Beginner's Manual (pp. 11-22). TIP Publishing Company. Kjaer , S. K., Frederiksen , K., Munk , C., Iftner , T., Long-term Absolute Risk of Cervical Cancer. Obstetrics & Gynecology.