Esophageal cancer - Nursing Case Study
Pathophysiology
• Primary mechanism: Esophageal cancer primarily develops due to genetic mutations in the cells of the esophagus. These mutations cause cells to grow and divide uncontrollably, forming a tumor. Two main types exist - Adenocarcinoma (originates in the mucus-secreting glands) and Squamous cell carcinoma (starts in the flat, thin cells lining the esophagus).
• Secondary mechanism: Environmental factors like chronic irritation of the esophagus can contribute to the disease. This includes prolonged exposure to stomach acid (GERD), smoking, alcohol consumption, and certain dietary factors.
• Key complication: As the cancer progresses, it can obstruct the esophagus causing difficulty in swallowing (dysphagia), which can lead to malnutrition and weight loss. The cancer cells can also metastasize to other organs, complicating treatment.
Patient Profile
Demographics:
64 years old, male, retired construction worker
History:
• Key past medical history: Chronic gastroesophageal reflux disease (GERD), heavy smoker for 40 years, alcohol abuse
• Current medications: Over-the-counter antacids, nicotine patches
• Allergies: No known drug allergies
Current Presentation:
• Chief complaint: Difficulty swallowing and significant weight loss
• Key symptoms: Progressive dysphagia, unexplained weight loss, chest pain, persistent cough, hoarseness, regurgitation of food
• Vital signs: Blood pressure 160/90 mmHg, pulse rate 95/min, respiratory rate 18/min, temperature 98.2°F, oxygen saturation 93% on room air.
Section 1
Change in Patient Status:
Over the past few days, the patient's condition has significantly deteriorated. In addition to his chief complaint of difficulty swallowing, he has developed severe chest pain. He describes it as a burning sensation that worsens with swallowing. Despite the use of over-the-counter antacids, the pain persists, suggesting that it might not be primarily related to GERD. He also reports increased fatigue, and his family members have noticed a change in his voice - it has become hoarse and weak. Although his temperature remains within the normal range, his respiratory rate has increased to 22 breaths/minute and pulse rate to 105 beats/minute, indicative of possible distress or anxiety due to his escalating symptoms. His blood pressure is still elevated at 165/95 mmHg, and his oxygen saturation has dropped to 90% on room air, which may suggest a decrease in his ability to oxygenate his blood adequately.
New Diagnostic Results:
Preliminary diagnostic tests were ordered to investigate the patient's symptoms further. An upper endoscopy was performed which revealed a large mass in the lower third of the esophagus, consistent with esophageal cancer. Biopsy of the mass confirmed the diagnosis of adenocarcinoma. A complete blood count (CBC) showed a hemoglobin level of 11 g/dL, indicating mild anemia, possibly due to chronic disease or nutritional deficiencies as a result of dysphagia. Liver function tests (LFTs) showed elevated levels of alanine aminotransferase (ALT) and aspartate aminotransferase (AST), suggesting potential liver involvement. A CT scan of the chest and abdomen was ordered to identify potential metastasis. As the patient's symptoms and diagnostic results suggest advanced disease, timely intervention is critical to manage his symptoms and prevent further complications.
Section 2
New Complications:
Within the next 48 hours, the patient's condition continues to decline. He has become increasingly lethargic, exhibiting decreased responsiveness to his environment and family members. He is experiencing severe difficulty swallowing even liquids, and he reports a significant increase in his chest pain, rating it as an 8 on a scale of 1-10. Despite his increasing oxygen demand, his oxygen saturation has further dropped to 86% on room air. His respiratory rate has increased to 24 breaths/minute, and his pulse rate is now at 110 beats/minute, suggesting that his body is trying to compensate for the decreased oxygenation. His blood pressure remains elevated at 170/100 mmHg, indicating a possible continued stress response.
Change in Patient Status:
The results from the CT scan revealed metastatic disease with multiple liver lesions, suggesting that the esophageal cancer has advanced to a late stage. The presence of these liver lesions could be contributing to the elevated liver enzymes observed in the LFTs. In light of these findings, his plan of care needs to be re-evaluated. The healthcare team needs to consider aggressive symptom management and possibly involving palliative care. The family must be educated about the progression of the disease, the options for care, and the patient's current prognosis. The clinical data suggests that the patient is experiencing severe distress due to his worsening condition, and his declining oxygen saturation levels may indicate a complication such as a pulmonary embolism or pneumonia.
Section 3
New Diagnostic Results:
The patient's latest blood work results show a significant increase in his liver enzymes, with Alanine Aminotransferase (ALT) at 120 U/L and Aspartate Aminotransferase (AST) at 150 U/L, both of which are above the normal range. His bilirubin level is also elevated at 2.2 mg/dL, which may indicate liver dysfunction. The Prothrombin Time (PT) has increased to 15 seconds, suggesting a possible coagulation disorder. In addition, his Complete Blood Count (CBC) report shows a reduced Hemoglobin (Hb) level of 9.2g/dL and a reduced Hematocrit (Hct) level of 27.3%, indicating a possible anemia. His white blood cell count is elevated at 16,000 cells/mm3, suggesting an infection or inflammation.
Response to Interventions:
Despite administering supplemental oxygen at 4L/min via nasal cannula, the patient's oxygen saturation remains low at 88%, indicating that the current intervention may not be sufficient. His heart rate remains tachycardic at 115 beats/minute, and his blood pressure is still elevated at 172/102 mmHg. The nursing team has attempted to manage his chest pain with Morphine Sulfate 5mg IV every 4 hours as ordered, but he continues to rate his pain as an 8 on a scale of 1-10. His lethargy and decreased responsiveness persist, suggesting that his overall condition is deteriorating. The healthcare team needs to review and possibly modify his plan of care, considering more aggressive symptom management strategies.
Section 4
New Complications:
The patient's condition continues to decline, and new complications have arisen. Despite the use of Morphine Sulfate, his pain rating remains high at 8/10, and he has started experiencing bouts of severe nausea and vomiting. His Glasgow Coma Scale (GCS) score has dropped to 12, suggesting a decrease in neurological function. Furthermore, his jaundice has worsened, his skin and sclera are noticeably more yellow, and his urine has become dark. His abdominal distension has also increased, and palpation reveals a firm, tender liver edge.
These symptoms, combined with the previously noted elevated liver enzymes, bilirubin level, and PT, indicate a likelihood of liver metastasis from the esophageal cancer. The healthcare team decides to order an abdominal ultrasound to confirm this suspicion. The patient's worsening anemia, as indicated by the low Hb and Hct levels, could be due to the gastrointestinal bleeding. The team will need to consider blood transfusion and endoscopic intervention. The increased WBC count suggests an infection; hence, blood cultures are ordered, and broad-spectrum antibiotics are considered.
This new development requires a complex, multidisciplinary approach to manage the patient's deteriorating condition. The healthcare team will need to adjust the care plan to address these new complications, giving priority to the patient's comfort and quality of life.
Section 5
Change in Patient Status:
The patient's condition continues to deteriorate as he becomes increasingly lethargic and disoriented, with a GCS score now at 10. His respiratory rate has increased to 26 breaths per minute and he is now requiring supplemental oxygen to maintain his O2 saturation above 92%. He has developed an irregular heartbeat with a rate of 110 bpm and his blood pressure has dropped to 100/60 mmHg. His temperature is slightly elevated at 38.3°C. The patient's pain rating is still high, and he has become less responsive to the Morphine Sulfate.
These changes in the patient's status suggest a worsening systemic condition, likely due to the spread of the cancer and a possible infection. The tachycardia could be a response to the increased demand for oxygen in the body or a sign of sepsis, while the hypotension could be indicative of septic shock or internal bleeding. The healthcare team will need to reassess the patient's pain management plan and consider escalating the treatment. The team also needs to prepare for potential resuscitation measures should the patient's condition continue to worsen. The patient's family needs to be informed of these developments and involved in decision making.