CASE PRESENTATIO

NBSN IV-3 GROUP III

ENT WARD

DISEASE ADENOID CYSTIC CARCINOMA, LEFT SUBLIGUAL GLAND

HEMI MANDIBULECTOMY

PERSONAL DATA Name: MR. X (not his real name) Age: 52y/o Sex: MALE Civil Status: MARRIED Religion: CATHOLIC Address: SAN FERNANDO, LA

UNION

Chief Complaint: SUBMANDIBULAR PAIN

Diagnosis: ADENIOD CYSTIC CARCINOMA, LEFT SUBLIGUAL GLAND

HEMI MANDIBULECTOMY

FAMILY BACKGROUND

Mr. X is a 52y/o, male, he was born on the 4th day of April 1959, born and grew up at San Fernando, La Union. There were 9 of them siblings, 2 boys and 7 girls, and his the 4th among them.

He has no medical history of any kind of illness from both sides of his parents. However, his cousin in his *** side has acquired breast cancer due to lifestyle. Mr. X’s first wife died because of hypertension and hepatitis condition, they were blessed of 3 children.

On year 2005, Mr. X got married for the second time to Mrs. X and blessed with 1 child. Mr. X supports his family as a famer and it is also his source of income. He spends most of his time under the sun for planting. Mr. X’s diet is more on vegetables and fish, they also prepares meat as their

dish once or twice a week. He prefers additional table spices ( e.g soy sauce, patis, vinegar, pepper, chili ). Mr. X is fun of smoking before, he can consumed 1 pack of cigarette per day or more for 20 years before he acquired such disease.

he also drinks beverages occasionally, he stopped smoking after his first surgery.

DEVELOPMENTAL DATA

ERIC ERICKSON› ADULTHOOD (25-65y/o)

GENERATIVITY vs. STAGNATIONPOSITIVE RESOLUTION

CREATIVITY, PRODUCTIVITY, CONCERN FOR OTHERS

NEGATIVE RESOLUTION

SELF-INDULGENCE, SELF-CONCERN, LACK OF INTEREST AND COMMITMENT

HAVIGHURST’S AGE PERIOD and DEVELOPMENTAL TASKS› LATER MATURITY

Adjusting to decreasing physical strength and health

Adjusting to retirement and reduce income

Adjusting to death of spouseEstablishing explicit affiliation

with one’s age group› Meeting social and civil obligation

› Establishing satisfactory physical living arrangement

HEALTH HISTORY

PAST HISTORY› Patient had an operation 2 years ago which was done to remove a mass on his submandibular area. He was discharged, improve after completing his treatment and antibiotics.

› 2 months PTC, pt. complained of pain on his left submandibular area that radiates to the whole head. No consultation was done and pt. self medicated with mefenamic acid and amoxicillin, but these afforded minimal relief of symptoms.

› A few days PTC, the pt. can no longer tolerate the pain on his

submandibular area. He sought consult in OPD in BCGH and was admitted.

› Year 2009, pt underwent surgery to remove his submandibular area.

› Previous accident and trauma› No history of cancer, DM, HPN, CAD, asthma and ulcer.

PRESENT HISTORY› The pt. present condition is submandibular pain

INCLUSIVE PERIOD OF HOPITALIZATION

Mr. X was brought to Baguio General Hospital’s Out Patient Department accompanied by his wife on the 10th day of September,2011.

HEALTH AGENCY Baguio General Hospital is a

MEDICAL TREATMENT

NURSING CARE PLAN ASSESSMENT

› “Masakit kapag kumakain ako” as stated

› With facial grimace noted when ingesting food

› With difficulty mastication noted› With difficulty swallowing noted

› With asymmetric facial contour on the left mandibular region

› With dental carries noted› With pink buccal mucosa› With swollen sublingual tongue noted

› No discharges noted› With poor appetite

NURSING DIAGNOSIS

› ALTERED NUTRITION: LESS THAN BODY REQUIREMENT r/t DIFFICULTY MASTICATION secondary to SUBLINGUAL CARCINOMA

OUTCOME IDENTIFICATION› AFTER

IMPLEMENTATION› ASSESSED GENERAL STATUS› OBSERVED PT. APPETITE› MONITORED BASELINE WEIGHT› PROVIDED SMALL FREQUENT FEEDING

RATIONALE› TO