Lupac, Virness Ivy S.

BSN3-3A

CASE ANALYSIS

1. George Smith, a 55-year-old patient is admitted to the intensive care unit after a thoracotomy
approach was used for an esophagectomy to remove an early stage adenocarcinoma of the distal
esophagus and gastroesophageal junction. The patient has a history of GERD and Barrett esophagus. The
patient sought medical treatment for dysphagia with solid foods, feeling that there was a lump in his
throat and substernal pain with swallowing and subsequent regurgitation of undigested food and the
development of hiccups. The patient has no other medical problems.

a. Describe the esophageal cancer that the patient has and how it relates to his history of GERD and
Barrett esophagus.

Esophageal cancer occurs in the esophagus which is a long, hollow tube that runs from our
throat to our stomach. The esophagus helps move the food we swallow from the back of our throat to
our stomach to be digested. Esophageal cancer usually begins in the cells that line the inside of the
esophagus. Esophageal cancer can occur anywhere along the esophagus. Esophageal cancer occurs
when cells in the esophagus develop changes (mutations) in their DNA. The changes make cells grow
and divide out of control. The accumulating abnormal cells form a tumor in the esophagus that can grow
to invade nearby structures and spread to other parts of the body.

There are different types of esophageal cancer, these includes: Adenocarcinoma, Squamous cell
carcinoma, and other rare types. In this patient’s case, he developed an early stage of adenocarcinoma.
Adenocarcinoma begins in the cells of mucus-secreting glands in the esophagus. Adenocarcinoma occurs
most often in the lower portion of the esophagus. Adenocarcinoma is the most common form of
esophageal cancer in the United States, and it affects primarily white men.

The most common symptom of GERD is heartburn or acid reflux. Acid reflux causes stomach acid
to splash up and into the lower portion of your esophagus. While your stomach has a lining that protects
it from the acid, your esophagus doesn’t. This means that the acid can cause damage to the tissue cells
in your esophagus. Sometimes the tissue damage from acid reflux can lead to a condition called  Barrett’s
esophagus. This condition causes the tissue in your esophagus to be replaced with tissue similar to
what’s found in the intestinal lining. Sometimes these cells develop into precancerous cells. A change in
the esophageal lining develops, a condition called Barrett’s esophagus which is associated with a higher
risk of esophageal cancer.
b. Explain the rationale for the early symptoms and late symptoms of esophageal cancer.

Early on, esophageal cancer usually has no obvious signs and symptoms. When they do appear,
the most common symptom is dysphagia. Other early signs and symptoms can include: unexplained
weight loss, chest pain, burning, or pressure, heartburn or indigestion, hoarseness, and coughing.
Dysphagia is another medical name for difficulty swallowing. People who have a hard time swallowing
may choke on their food or liquid when trying to swallow. 

Esophageal symptoms tend to worsen as the disease progresses and the cancer metastasizes.

Dysphagia, for example, may reach a point when a liquid-only diet is necessary. Other end stage signs
and symptoms of esophageal cancer can include: worsening cough and sore throat, labored breathing,
greater hoarseness and difficulty speaking above a whisper, hiccups, nausea and vomiting, bone and
joint pain.

 c. What course of cancer treatment should the nurse anticipate that the patient in this case study would
have?

Options for treatment typically include endoscopic treatments such as photodynamic therapy

(PDT), radiofrequency ablation (RFA), or endoscopic mucosal resection (EMR). Long-term follow-up with
frequent upper endoscopy is very important after endoscopic treatment to continue to look for pre-
cancer (or cancer) cells in the esophagus.

Another option is to have the abnormal part of the esophagus removed with an esophagectomy.
This is a major operation, but one advantage of this approach is that it doesn’t require lifelong follow-up
with endoscopy. Esophagectomy is the main surgical treatment for esophageal cancer. It is done either
to remove the cancer or to relieve symptoms. During an open esophagectomy, the surgeon removes all
or part of the esophagus through an incision in the neck, chest or abdomen. The esophagus is replaced
using another organ, most commonly the stomach but occasionally the small or large intestine.

 d. What nursing care should be provided for the patient in the intensive care unit in the early
postoperative period?

Nursing interventions include monitoring vital signs, airway patency, and neurologic status;
managing pain; assessing the surgical site; assessing and maintaining fluid and electrolyte balance; and
providing a thorough report of the patient's status to the receiving nurse on the unit, as well as the
patient's family.
e. Explain the care the nurse should provide when the patient begins to eat.

Most patients who have this surgery will have a feeding tube put in. This will help them get extra
nutrition until they can go back to their regular diet. This tube is called a jejunostomy tube or J-tube. The
tube is put in through the belly and into a part of the small intestine. The doctor can give liquid nutrition
(tube feedings) through the J-tube until the patient can eat enough food by mouth. Tube feedings starts
in the hospital a few days after surgery. Tube feedings often starts at a low, continuous rate. If the
patient tolerates the feeds, with no severe cramping, nausea, and vomiting, we increase the rate to
provide more calories. Nursing care includes regular assessment of the J-tube with proper hand washing
before and after the assessment, assessing the patient’s tolerance for food intake, and also
encouragement and patient education is important.

2. Mr. Owens is a 62-year-old man who underwent a neck dissection yesterday due to cancer of the
mouth. You are the nurse assigned to care for Mr. Owens during his first postoperative day. Initial
assessment finds Mr. Owens sitting up in bed; he is drowsy, but oriented ×3 when aroused. He has
significant edema in his neck and mouth area, but does not appear to be in respiratory distress. His
respiratory rate is 16 to 18, and his oxygen saturation is 96% on 40% oxygen via face tent. He has two
peripheral IV lines both infusing Lactated Ringer solution at 75 mL/hr. Two Jackson--Pratt drainage tubes
are partially filled with serosanguinous drainage. 

 a. What is the rationale for the patient being placed in Fowler position after surgery?

Fowler's position facilitates the relaxing of tension of the abdominal muscles, allowing for

improved breathing, to prevent aspiration during swallowing, to decrease swelling, and to decrease
venous pressure to reduce pain. In immobile patients and infants, the Fowler's position alleviates
compression of the chest that occurs due to gravity. In this patient’s case, he had a neck dissection;
therefore we wouldn’t want a lot of pressure to be put on this area hence placing the patient in Fowler’s
position.

 b. The nurse notes that there has been 240 mL output in the drainage tubes during the first 24 hours
after the surgical procedure. What should the nurse do?

The nurse should note the output amount. When the output comes into less than 25ml per day,
two days in a row, the nurse should notify the doctor because this indicates for removal of the dp drain.
At this patient’s condition, the nurse should monitor the amount and color of drainage each shift and
reposition the patient every 2 hours.
c. Postoperatively, the nurse identifies that the patient is at risk for imbalanced nutrition, less than body
requirements related to anorexia and dysphagia. The nurse instructs Mr. Owens to eat soft food and
suggests that he tilt his head to the unaffected side to facilitate swallowing. What is the rationale for
these instructions?

This is done to avoid pain and discomfort on the surgical site which reduces dysphagia and
facilitates swallowing. Soft foods are recommended to promote digestion, and are taken in small,
frequent feedings. Swallowing food with liquid could also help. Instruct patient to avoid food that can
cause irritation like spicy foods.

d. In reviewing Mr. Owens’ medical record, what findings in his health history are associated with
development of oral cancer?

According to studies, people older than 45 have an increased risk for oral cancer, although this
type of cancer can develop in people of any age; Mr. Owen is 62 years old. His history of neck dissection
can be associated with his development of oral cancer due to the growth of cells.

References:

https://www.mayoclinic.org/tests-procedures/esophagectomy/about/pac-
20385084#:~:text=Esophagectomy%20is%20the%20main%20surgical,the%20neck%2C%20chest%20or
%20abdomen.

https://www.cancer.org/cancer/esophagus-cancer/treating/by-stage.html

https://www.uwhealth.org/healthfacts/nutrition/368.pdf

https://www.cancer.net/cancer-types/oral-and-oropharyngeal-cancer/risk-factors-and-
prevention#:~:text=Age.,risk%20of%20oral%20cavity%20cancer.