STI COLLEGE STA.

MARIA

A CASE PRESENTATION PRESENTED TO MR. RONALDO V. RAYMUNDO

BY: MARIA ANGELICA P. TORTOSA

January 30, 2013

OBJECTIVES General Objective: Enable us, nursing students, to have an enhanced understanding of the condition, Hepatocellular Carcinoma. Specific Objectives: To determine the livers anatomy and its normal function. To gain knowledge about the causes and risk factors of Hepatocellular Carcinoma. To elaborate the different nursing and medical interventions that can be rendered to clients with Hepatocellular Carcinoma. To explain the different laboratory data and the pertinent findings about the clients condition. To provide health teachings to the client and family members on how they can manage and prevent the occurrence of Hepatocellular Carcinoma.

INTRODUCTION Is the primary malignancy of the liver Most common tumors worldwide Has poor prognosis.

RISK FACTORS Alcoholism Chronic Hepatitis B/C infection Cirrhosis, regardless of type Chronic aflatoxin Arsenic-contaminated water Carcinogens in food

CLASSIFICATION OF CANCER BASED ON ORIGIN OF CELL-TYPE Carcinomas Adenocarcinomas Sarcomas Leukemias and Lymphomas WARNING SIGNALS OF CANCER C-hange in bowel or bladder habits A-sore that does not heal U-nusual bleeding or discharge T-hickening or lump in the breast or elsewhere I-ndigestion or difficulty swallowing O-bvious change in wart or mole N-agging cough or hoarseness U-nexplained anemia S-udden unexplained weight loss

MANIFESTATIONS Right upper quadrant pain Anorexia Malaise Lethargy Jaundice Manifestations of liver failure DIAGNOSTIC PROCEDURES Liver Function Tests AFP Tests Imaging tests Liver Biopsy NURSING DIAGNOSIS Acute Pain Imbalanced Nutrition less than body requirements NURSING MANAGEMENT Provide ongoing assessment. Provide pain relief. Promote nutritional balance. Promote measures to increase activity tolerance. Protect skin integrity. Enhance mental status. Provide client and family teaching. Promote a positive body image. MEDICAL MANAGEMENT Surgery Liver Transplant Chemotherapy Radiation therapy Drug therapy

The Hepatobiliary System GALL BLADDER

 Pear-shaped, hollow, saclike organ Connected to the common bile duct by the cystic duct COMMON HEPATIC DUCT union of right and lower hepatic ducts which transport bile out of the liver CYSTIC DUCT coming from the gallbladder COMMON BILE DUCT union of the common hepatic duct and cystic duct PANCREAS Islets of Langer-hans (endocrine): insulin and glucagon Acini (exocrine) : digestive enzymes Pancreatic Duct: joins the common bile duct and empties into the duodenum AMPULLA OF VATER union of the common bile duct and pancreatic duct which empties into the duodenum SPHINCTER OF ODDI controls secretions from the liver, pancreas, and gallbladder into the duodenum of the small intestine

ANATOMY OF THE LIVER The liver is located in the upper right-hand portion of the abdominal cavity. The liver holds about one pint (13 percent) of the body's blood supply at any given moment. The liver consists of two main lobes, both of which are made up of thousands of lobules. These lobules are connected to small ducts that connect with larger ducts to ultimately form the hepatic duct. A mesenteric ligament separates the right and left lobes. The liver is encased in a fibroelastic capsule. Liver tissue consists of units called lobules, which are composed of plates of hepatocytes. Sinusoids are lined with Kupffer cells.

 The hepatic duct transports the bile produced by the liver cells to the gallbladder and duodenum. FUNCTIONS OF THE LIVER Secretes bile Stores fat-soluble vitamins Metabolizes bilirubin Stores blood and releases blood into the general circulation during hemorrhage. Synthesizes plasma proteins. Synthesizes clotting factors which are necessary for blood clotting. Synthesizes fats from carbohydrates and proteins to be either used for energy or stored as adipose tissue. Synthesizes phospholipids and cholesterol necessary for the production of bile salts, steroids hormones, and plasma membranes. Regulation of blood levels of amino acids, which form the building blocks of proteins. Releases glucose during times of hypoglycemia Takes up glucose during times of hyperglycemia and stores it as glycogen or convert it as fat. Alters chemicals, foreign molecules, and hormones to make them less toxic. Stores iron as ferritin, which is released as needed for the production of RBC.

PATHOPHYSIOLOGY

Risk Factors: Alcoholism

Damage to Hepatocellular DNA

Interferes normal hepatic function

Signs and Symptoms

GENERAL DATA

Name: Age: Address:

MR. A.L 73 Y/O 1118 Kaybitin Road San Gabriel, Sta. Maria Bulacan

Date of Admission: Occupation: Religion: Birthday: Birthplace: Status: Chief Complaint: Final Diagnosis: Attending Physician: Pertinent Physical Finding:

November 25, 2012 Pastor Born Again December 31, 1939 Negros Occidental Married Abdominal Pain HEPATOCELLULAR CA,BPH Dra. Asuncion F. Dela Cruz M.D

BP- 100/60mmhg T- 36.3C

RR- 24cpm PR- 74bpm

HISTORY OF PRESENT ILLNESS On August 2012, 3 months prior to admission the patient had experienced abdominal pain, he went to Chinese General Hospital and was found of having mass in the liver. The doctor gave him medication which is intended to dissolve the mass. He takes it 15 capsules per day and experienced severe body malaise. He stops using the medication. Until on November 25, 2012, three hours prior to admission the patient complained of body weakness and severe abdominal pain, and was rushed then to RMMMH. It was on the 25th day of November 2012, when our group had our duty at Male Medical Ward of RMMMH, on the same day patient A.L was admitted to the said hospital. His admitting impression is HEPATOCELLULAR CARCINOMA, BPH. Dra. Dela Cruz as the admitting physician made the following orders: To MMW Secure consent VS q 4 hrs and record Soft diet Laboratory: CBC, UA, CBG CxR, 12L ECG-defer FBS, SGPT: HBsAg det UTZ, HBT IVF: D5NM 1L X 8hrs SD: Amino Acid 200 ml IV x 4 hrs then q 12 hrs for 2days Therapeutics: Cefuroxime750mg IV q 8 hrs ANST ( ) Ketorolac 1 amp IV STAT, PRN abdominal pain Silymarine/ B Complex 1 cap BID

-oxygen inhalation 4L/min -refer

Patient A.L was received on bed on semi-fowlers position, awake and coherent with IVF #1 D5NM 1L @ the level 350 cc, regulated @ 31 gtts/ min, infusing well @ right hand around 3:30 pm. Initial Vital signs taken as follows: BP = 100/60 mmHg RR = 24bpm PR = 74cpm T = 36.3 C

On the follow up assessment the patient was observed ( + ) yellowish sclera and yellowish discoloration of the skin with an abdominal girth of 85cm.

On November 26, 2012: Dra. Dela cruz ordered: - c/o UTZ HBT in AM - cont present meds. - Secure amino acid solution November 27, 2012: - IVF to follow D5NM 1L x 12 hrs PAST MEDICAL HISTORY According to Mr. A.L, he was hospitalized two times. His first hospitalization was on 1968, the patient experienced sudden rise in blood pressure and was admitted at San Lazaro Hospital. Also on 1975, he was diagnosed with AMI. FAMILY HISTORY According to Mr. A.L, his father died because of heart attack and his mother because of respiratory problems. The family has no known history of asthma and no one in the family had the same disease except from the brother of his father who had Gastric Cancer.

SOCIAL HISTORY Mr. A.L is residing at San Gabriel, together with his wife and five children. According to him he worked before as a kargador on Pier for 1 year and deliver vegetables in Divisoria for almost 23 years before he became as a pastor on 1998. LIFESTYLE The patient confessed to having drunk steadily for a period of 25 years and smoked 3 pack of cigarettes every day. He was also fond of eating fatty foods.

PHYSICAL ASSESSMENT INSPECTION GENERAL Conscious and coherent (+) yellowish discoloratio n Icteric sclera PERRLA Symmetrical Symmetrical Distended (85cm) UPPER EXTREMITIES LOWER PALPATION PERCUSSION AUSCULTATION -

SKIN

Warm to touch

EYES

HEAD

EARS NOSE THROAT NECK

(+)tenderness Poor capillary refill Poor capillary refill

CHEST ABDOMEN

Skin Mild jaundice was noted on his skin. He has dry skin with a rough texture. Upon palpation, the skin is warm Eyes The sclera is moist and yellowish in color. The iris appears to be black on both eyes. Round and reactive to light and accommodation. He verbalized that he can see both near and far objects. No scratches and discharges on both eyes noted. Ears Upper margin of the pinnaes are in line with the outer canthi of the eyes. Ears are firm and non tender. Signs of lesions, lacerations, swelling and bruises were not seen upon inspection. He was able to answer the questions correctly, which reveals that he does not have any hearing problem. Mouth Gums and buccal mucosa are pinkish in color. Tongue is in the midline of the mouth. Bleeding and ulceration were not seen upon inspection. Chest and Lungs Chest muscle expansion is symmetrical and painless. He was not in respiratory distress; his respiration rate is 24 cycles per minute. Abdomen Patients abdomen is distended with abdominal girth of 85cm. There is tenderness upon palpation. Four quadrants of the abdomen have bowel sounds. Extremities No signs of deformities on both upper and lower extremities.

LABORATORY BLOOD CHEMISTRY November 26, 2012

TEST SGPT The most sensitive indicators of liver cell irritation or damage. The activity of this enzyme is measured in blood plasma. Elevated levels can be an indication of viral hepatitis and other forms of liver disease. GLUCOSE This test of serum or plasma is order to monitor if blood sugar level is within normal range.

NORMAL VALUES

RESULTS

4-39 IU/l

52.1 IU/l

65-110 mg/dl

100.7 mg/dl

HEMATOLOGY TEST HEMOGLOBIN To identify the amount of O2 carrying protein contained within the RBC. Increased hemoglobin indicates dehydration and excessive plasma loss. HEMATOCRIT To identify the percentage of the blood volume occupied by red blood cells. Increased hematocrit indicates dehydration. WBC Count To determine infection or inflammation in the body and monitor its 4.0 11.0 x 109/ L 6.9 / L M: 0.40 0.48% 0.58% M: 135-160 g/l 197.2 g/l NORMAL VALUES RESULTS November 25, 2012

responses to specific therapies. Differential Count LYMPHOCYTES To identify if there is an abnormal amount of lymphocyte that may indicate viral infection. HBsAg Non-Reactive 0.25 0.40 0.35

ULTRASOUND OF WHOLE ABDOMEN October 3, 2012

The liver is normal in size with homogenous parenchyma. There are 2 well-defined heterogenous mass seen in right lobe, measuring 12.5 x 8.7 and 5.8 x 3.0cm. Gallbladder measures 4.6 x 2.3 cm, with no intraluminal echo. Its wall is not thickened. Intrahepatic and extrahepatic ducts are not dilated. Pancreas and spleen are within normal limits in size and echopattern. No focal mass.

Both kidneys are normal in size and echo pattern. Corticomedullary junctions are distinct.

Right measures 9.2 x 5.5 x 4.4cm, with a corticomedullary thickness of 1.2cm. Left measures 9.4 x 4.5 x 4.8cm, with a corticomedullary thickness of 1.3cm. No mass, lithiasis nor hydronephrosis.

Urinary bladderis distended with smooth mucosa. No intraluminal density seen. Wall is not thickened. Pre-voiding volume is 151cc.post-void shows 75cc of residual urine.

Prostate gland is enlarged, measuring 4.9 x 4.5 x 4.8cm. (volume of 57 grams) with homogenous parenchyma. No focal mass noted.

IMPRESSION: SOLID HEPATIC MASSES, RIGHT LOBE, CONSIDER HEPATOCELLULAR CA. ENLARGED PROSTATE GLAND. 50% RESIDUAL URINE.

DISCHARGE PLANNING M Instruct the patient and family to follow the home medications as prescribed by the physician regarding proper administration, dosage, time, frequency and to take medications with food if not contraindicated. Encourage early ambulation if not contraindicated or promote exercise to the client especially ROM, and advise patient to have adequate rest and sleep. Explain the need of treatment after discharge and must take it seriously so as to prevent such complications to the patient. Encourage patient to perform proper personal hygiene to promote comfort and cleanliness which is very much needed in the therapeutic process. Inform the patient that follow-up check-up is important to have continuous monitoring and care. Encourage patient to eat a variety of nutritious foods, but preferably to avoid drinking liquors and also smoking. Provide bleeding precautions.

Date of Discharge: December 3, 2012 OPD check-up on: December 10, 2012 Take home medications: Cefuroxime 500mg BID Spirinolactone OD Captopril BID