S.

NO CONTENT PAGE NO
I INTRODUCTION
II OBJECTIVES
III HEALTH ASSESSMENT
A)HEALTH HISTORY
B)PHYSICAL EXAMINATION
C)SYSTEM REVIEW
D) INVESTIGATION
IV DISEASE CONDITION
A)DEFINITION
B)REVIEW OF ANATOMY &
PHYSIOLOGY
C)ETIOLOGY
D) PATHOPHYSIOLOGY
F)CLINICAL MANIFESTATION
G)DIAGNOSTIC EVALUATION
H)MANAGEMENT-MEDICAL
-SURGICAL
-NURSING
I)COMPLICATION
J)PATIENT MANAGEMENT-MEDICAL
-SURGICAL
NURSING
V LIST OF NURSING DIAGNOSIS
VI NURSING CARE PLAN
VII HEALTH EDUCATION
VIII SUMMARY
IX CONCLUSION
X BIBLIOGRAPHY
INTRODUCTION

Salivary gland cancer starts in one of the salivary glands. It’s not just a single

disease. There are actually several different salivary glands found inside and

near your mouth. Many types of cancer and benign (non-cancerous) tumors can

develop in these glands.

ABOUT THE SALIVARY GLANDS

Salivary glands make saliva – the lubricating fluid found in the mouth and

throat. Saliva contains enzymes that begin the process of digesting food. It also

contains antibodies and other substances that help prevent infections of the

mouth and throat.

The parotid glands, the largest salivary glands, are just in front of the ears.

About 7 out of 10 salivary gland tumors start here. Most of these tumors are

benign (not cancer), but the parotid glands still are where most malignant

(cancerous) salivary gland tumors start.

The submandibular glands are smaller and are below the jaw. They secrete

saliva under the tongue. About 1 or 2 out of 10 tumors start in these glands, and

about half of these tumors are cancer.

The sublingual glands, which are the smallest, are under the floor of the mouth

and below either side of the tongue.

MY patient [Link] 45years old male got admitted with the

complaints of Neck pain radiating to left [Link] for 1 week;Vomiting 2

episodes,Liquid,Clear,Non projectile vomiting,No bile or [Link]

of neck over 2 [Link] as tumor in parotid gland and advised to do

[Link] superficial paroitoidectomy done on 29/08/2015

And discharged on 7/09/[Link] histopathology report- ACINI CELL

[Link] Kamuthi GH hospital advised to take further management

in MMC [Link] patient got admitted on 22/09/2015

OBJECTIVES:

 To establish rapport with the Patient

 To identify the patient problem

 To identify the patient needs of the patient

 Ensure the patient disease condition

 To improve knowledge about the disease condition

 To enhance the nursing care

 To prevent from complication of the disease condition.

 To ensure the effective nursing care implementation to the

patient.

 To identify the effectiveness of nursing care.

 To educate the patient about his disease condition.

 PATIENT PROFILE:

NAME OF THE PATIENT : [Link]

AGE : 56YRS

SEX : MALE

WARD : POST OPERATIVE MALE MEDICAL

WARD

UNIT : 214

MRD NUMBER : 79970

RELIGION : HINDU

MARITAL STATUS : MARRIED

E DUCATION QUALIFICATION : UNEDUCAED

OCCUPATION : FARMER

FAMILY INCOME : Rs.2000/-

ADDRESS : 1/42, EAST STREET

ALLAMPATTI,

VIRUDHUNAGAR DISTRICT .

SOURCE OF DATA :CASE SHEET,PATIENT’S WIFE.

DATE & TIME OF ADMISSION : 18/11/2018 & 8.15A.M

MEDICAL DIAGNOSIS : CANCER TONGUE LEFT LATERAL

NAME OF SURGERY :WIDE LOCAL EXCISION WITH LEFT

SUPROMYOHOID NECK
DISSECTION

DATE OF SURGERY : 6/12/2018

NO. OF POST OPERATIVE DAYS : 1st POD

CHIEF COMPLAINTS

Patient came with H/O painless ulceration in the tongue in left lateral
side for past two months and excessive salivation present for past 10 days.

PRESENT MEDICAL ILLNESS:

Patient had complaints of painless ulceration for past 2 monthsand excessive

salivation for 10 [Link] he went near by private hospital and then referred to
Government Rajaji Hospital, Madurai.

PAST MEDICAL ILLNESS:

There is no history of communicable and non communicable diseases such as

tuberculosis,Diabetes mellitus,Hypertention and seizure disorder.

PAST SURGICAL HISTORY:

There is no history of any surgical intervention.

FAMILY HISTORY:

 Patient is in nuclear family.

 He is born in his home.

 He is the breadwinner of her family.

 There is an history of hypertension of her mother .

 There is no history of PTB, BA, CAD, CHD, seizure disorder, etc.

GENOGRAM:

(T2DM , Ca) ( HTN, T2 DM)

56YRS 50 yrs ( HTN,T2DM) 40yrs

KEYS :

died male

died female

- patient

- female
SOCIO ECONOMIC HISTORY:
Type of housing: pucca

Own/ rented: own

Water facility : corporation water from street pipes

Drainage facility : adequate, closed drainage system

Cross ventilation : adequate

Disposal to refuse : street dust bins

Lighting facility : adequate

Pet animals : no

PERSONAL HISTORY:

Place at birth : home

Relationship with neighbourhood and family : good and maintained.

Food type: mixed diet

Pattern of rest and sleep: rest is adequate and he sleeps 8 hours per day.

Social and recreational preferences: He attend close relative marriages,

recreational preferences is watching T.V

 Habit of alcohol,

 Use to consume monthly twice.

 He started to take alcohol on 20 years old due his friends compultion.

and NO Habit of Smoking,tobacco chewing.

Activities of daily living: Normal ADL is maintained.

Bowel and bladder pattern: he pass motion 1 time / day, and he pass urine 5-6
times/ day. His bowel and bladder pattern is normal.

PHYSICAL EXAMINATION:

GENERAL APPEARENCE:

 Patient is conscious and oriented to time ,place, and person.

 Patient looks dull and inactive.
 Looks unhappy and worried.

HEAD:

 Scalp is clean.
 Hair is black and grey in colour.
 Hairs are evenly distributed.
 No scar is seen.

SKIN:

 Skin is warmth.
 Skin colour is pale.
 Skin integrity is poor.
 Skin turgor is impaired.
 No lesion is seen.

EYES:

 Vision normal.
 Sclera is pale.
 Eye ball movement is normal.
 Eye lashes are evenly present.
 Conjunctiva is white in colour.

EARS:
  Hearing acuity is normal.
 Wax is present.
 Ear pinna is normal.

NOSE:

 No Nasal septum deviation.

 Nasal is clean.
 Bilateral air entry is present.

MOUH:

 Lips:
- Pink in colour.
- Dry which indicates dehydrated.
- No crackles is seen.
 Tongue :
- Pallor
- Severe ulceration present
- Excessive salivation present.
 Teeth:
- Teeth alingnment is normal.

NECK:

 Trachea present in midline.

 Range of motion is normal.
 Mild swelling is present over the neck.
 Carotid pulse is felt.

CHEST:
  Chest wall movement is symmetrical.
 No scar is seen.
 Chest is evenly distributed.

ABDOMEN:

 Abdomen soft.
 No scar is seen.
 Bowel sound is heard all quadrant.
 Umbilicus present at centre of the abdomen.

UPPER LIMBS:

 Capillary refill time is 3 seconds.

 Range of motion is normal.

LOWER LIMBS:

 Range of motion is normal.

 No scar is seen.
 No wound, blisters & discharges is seen.

GENITOURINARY:

 Patient maintained personal hygiene.

 Anus is patent.

CENTRAL NERVOUS SYSTEM:

 Glassgow coma scale is 15/15.

 Oriented to time, place, and person.
 Immediate, recent and remote memory is intact.
 Mood and affect are normal.
 Patient is dull.
 Cranial nerve functions are normal.
  No evidence of brudinski sign.

RESPIRATORY SYSTEM:

INSPECTION:

 Chest wall movement is symmetrical.

 Bilateral air entry is present.
 Respiratory rate is 28breath/minute.

AUSCULTATION:

 Breath sound is heard.

PERCUSSION:

 No Dull resonance is heard over the lung field.

CARDIOVASCULAR SYSTEM:

INSPECTION:

 Carotid pulse is felt.

 Pulse rate is 82 beats/minute.
 No jugular vein distention.
 Full volume felt at each peripheries.

PALPATION:

 Apical pulse is felt during palpation.

 Pulse rate is 84 beats/minute.

AUSCULTATION:

 S1S2 sound is heard.

 Cardiac murmur is not present.

PERCUSSION:
  Normal resonance is heard.

GASTRO INTESTINAL SYSTEM:

INSPECTION:.

 Tongue ulceration
 Umbilicus normal.
 Abdomen moves with respiration.
 Skin over abdomen is normal.
 No dilated vein/ sinus.

PALPATION:

 Abdomen is soft, non tender, not in warmth.

 No spleenomegaly, hepatomegaly.
 No evidence of fluid thrill.

PERCUSSION:

 Normal .
 No evidence of fluid thrill.

AUSCULTATION:

 Normal bowel sounds are heared in the four quadrants.

 Bowel movements are present.

MUSCULO SKELETAL SYSTEM:

 Peripheral pulse is felt.

 Muscle power is poor.
 Upper extremity range of motion is normal.
 Lower extremity range of motion is normal.
 No evidence of congenital abnormalities.
ENDOCRINE SYSTEM:

 No evidence of hot and cold intolerance.

 History of diabetes mellitus.
 No complaints of hyper or hypothyroidism.

LYMPHATIC SYSTEM:

 Absence of generalised lymphadenopathy and local lymphadenitis.

GENITOURINARY SYSTEM:

 he maintained personal hygiene.

 Anus is patent.
 His bowel and bladder pattern is normal.
 No oliguria, dysuria.

INTEGUMENTARY SYSTEM:

 Skin turgor is reduced.

 Dark in complextion.
 Temperature is normal.
 No complaints of inflammation,pigmentation,paresthesia.

VITAL SIGNS:

TEMPERATURE : 98.4 F

PULSE : 82 beats/ minute

RESPIRATION : 28 breath / minute

BLOOD PRESSURE : 110/80 mm hg

OXYGEN SATURATION:
The oxygen saturation of the patient not in room air is 98%

Pain -------- No 8. Severe pain

0 1 2 3 4 5 6 7 8 9 10

ANTHROPOMETRIC MEASUREMENT:

HEIGHT : 158CM

WEIGHT : 54KG

BMI : WEIGHT/HEIGHT m2

= 24Kg/ m2

INVESTIGATION:
S.N Name of the Patient Normal
Impression
O investigation value value
1. Haemoglobin 8.7 g/dl 12-16 g/dl Anaemia
80-120
2. Glucose 82 mg/ dl Normal
mg /dl
3. [Link] 20 15-45 Normal
4. [Link] 1.0 0.6-1.2 Normal
135-145
5. [Link] 135mEq/L Normal
mEq/L
3.5-
6. Sr. Potassium 3.8mEq/L Normal
4.5mEq/L
90-
7. Chloride 96mEq/L Normal
105mEq/L
8. Total bilirubin 2.0mg/dl 0.2-1mg/dl Incresed
0.2-
9. Direct bilirubin 0.7 mg/dl Normal
0.8mg/dl
10. Indirect bilirubin 1.3
20-40
11. SGOT 29mmol/dl Normal
Mmol/dl
25-
12. SGPT 23mmol/dl Normal
50mmol/dl

Base of the
11. CECT skull and
root of neck

ANATOMY AND PHYSIOLOGY

Pink ,Moist ,Solid Conical muscular organ ,in floor of mouth
• Partly oral and partly pharyngeal in position
• Covered by mucous membrane
attached by its muscles to
• Hyoid bone
• Mandible
• Styloid process
• Soft palate &
• Pharyngeal wall
Main Functions - Organ of
Deglutition
Taste &
Speech
• Helps in mastication ,
• Helps in moistening lips
• Clinically – Mirror of GIT ailments
Functions
• Utilised in gestures and postures of facial expression
• Thermo – regulation in lower animals
Parts
• Tip (Apex)
• Base
• Root
Two surfaces
Dorsal & Inferior
Two lateral margins
• Tip– Ant. Free end directed forward in contact with the incisor at rest
• Base – directed backward towards oro-pharynx ,formed by post 1/3rd
Root
• Attached to hyoid and mandible and is in contact inferiorly with geniohyoid and mylohyoid
muscles

Dorsal Surface
• Convex on all sides
• Covered with moist and pink mucous membrane
• Divided by a V shaped(sulcus terminalis) into ant. 2/3rd (oral or pre-sulcal )facing upward
and post.1/3rd (pharyngeal or post-sulcal) facing backward at rest
• Limbs passes anterolaterally from a median depression( foramen caecum) indicate
site of upper end of thyroid diverticulum
Presulcal part
• Mucous memb. Adherent to
underlying muscles by lamina
propria
• Provided with numerous
papillae of different types
• Each papilla is a projection of
lamina propria covered by
mucous memb (characterstic
roughness)
Types of Papilla
• Vallate
• Fungiform
• Foliate
• Filliform
Vallate
• 8-12 in no. , 1-2 mm diameter
• Arranged in V shaped , single row
• Immediately in front of sulcus
Fungiform
• Rounded reddish elevation , distrbuted discretely
numerous along margins and tip of tongue –bright
red colour (contain taste buds)
Foliate
3-4 vertical mucous folds at margins of tongue in front of sulcus (contain taste buds)
Filiform
Numerous tiny conical projections over the entire dorsal surface of ant. 2/3rd of tongue
appearance)
Post sulcal (Pharyngeal) part
• Lie behind palatoglossal arch and sulcus & form ant. wall of oropharynx
• Connected to epiglottis by a median and a pair of lateral glosso-epiglottic folds with a
depression in b/w (epiglottic vallecula)
• Mucous memb. Devoid of papilla
• Separated from underlying muscles by a loose sub mucous coat which contain mucous
and serous glands and numerous lymphoid follicles(Lingual Tonsil)
Tongue – Inferior surface
• Reflected on floor of mouth
• Covered by mucous memb.
• devoid of Papillae
Features
• (Frenulum) Median fold connecting tongue to floor
• Applied – Tongue Tie
• Sublingual papilla
• Deep lingual veins prominance
Tongue - Musculature
• Tongue divided into two symmetrical halves by a median fibrous septum
• Each half contain striated muscles arranged in two groups
• Extrinsic& Intrinsic
Tongue - Musculature
Extrinsic – Five Pair
Connect to
• Genio-glossus (mandible)
• Hyo-glossus (Hyoid)
• Chondro-glossus
• Stylo-glossus (Styloid process)
• Palato-glossus (Palate)
Alter position of tongue
Tongue - Musculature
Intrinsic muscles –
occupy upper part & are Attached to submucous
fibrous layer and to median fibrous septum
• Superior Longitudinal
• Inferior Longitudinal
• Transverse muscle
• Vertical muscle
Alter shape of Tongue

Tongue - Musculature
Genioglossus
• Fan shaped , form main bulk of tongue
Origin – Sup. Genial tubercles of mandible
Insertion
• Lowest fibers – to body of hyoid
• Intermediate– pass deep to hyoglossus and are
continuous with middle constrictor of pharynx
• Upper – turn forward and upward from root to apex
Action -Protrude tip of tongue and make dorsal surface concave
Hyoglossus
• Quadrilateral muscle
Origin
• Upper surface of greater cornu and partly from body of hyoid
• Passes upward & forward under cover of mylohoid
Insertion
side of tongue b/w styloglossus laterally and
inferior longitudinal muscle medially
Action
Depresses sides of tongue , make dorsal surface
Convex
Chondroglossus detached part of hyoglossus, seperated by genoiglossus
Originate from lesser cornu & attached to side of tongue
Styloglossus
Arise from tip of styloid process & stylomandibular
ligament
Passes downward and forward
Inserted to side of tongue
Oblique fibers interdigitate with hyoglossus
Longitudinal fibres continue with inf. Longitudinal muscle
Action – retracts tongue backward & upward Antagonist in action to genioglossus

Muscles altering shape of tongue

Making dorsum concave
• Genioglossus , Sup. Longitudinal , Vertical , Styloglossus
Making dorsum Convex
• Hyoglossus, Inferior Longitudinal
Shortening of tongue
• Superior, inferior longitudinal , vertical
Muscles Elongating
• Transverse

DEFINITION
 Oral tongue is an area limited posteriorly by circumvallate papillae. These cancers are
a distinct clinical entity and must be differentiated from the cancers of the base of tongue.
This write up is restricted to the cancers arising in oral tongue.
Most common site of involvement is lateral border of tongue accounting for 85% of cases.
Dorsum,ventral surface and tip of the tongue (5% each) form rest of the cases.
RISK FACTORS
History
• History of habits and addictions
•Medical and family history, including any prior malignancy
• Coexisting co morbidity
• Prior treatment with details
Examination
Important points to consider are –
• Size
• Location
• Extent
• Posterior- base of tongue / vallecula / tonsil involvement
• Lateral/ deep extent of the tumor, relationship to midline, mandible and hyoid
• Ankyloglossia
• Hypoglossal nerve palsy
• Cervical adenopathy
Histological Diagnosis
i. Biopsy
Biopsy of the lesion to confirm the presence of carcinoma and to know the histological type.
Assessment of grading is difficult and not mandatory on a biopsy specimen.
•• Punch biopsy from most representative area avoiding obviously necrotic areas
•• Incisional biopsy for submucosal lesions/patch/verrucous lesions when punch biopsy is not
feasible or non contributory.
ii Scrape cytology
Acts as an adjunct and not a substitute for formal biopsy. A negative scrape cytology with
strong clinical suspicion warrants biopsy. Occasionally the confirmatory biopsy that follows
positive scrape cytology may be negative. This is usually due to inadequate sampling of a
representative area from the lesion. The biopsy needs to be repeated in such cases.
Imaging
i. Pretreatment imaging
a. OPG
Evaluating bone erosion in tongue cancers due to low specificity owing to high
incidence of periodontitis and odontogenic infections . It is useful for planning
mandibulotomy and for dental treatment prior to radiotherapy.
b. High resolution Ultrasonography (USG) with guided FNAC
c. CT/MRI
d. PETCT- for evaluating distant metastases in stage III & IV tongue cancers

TNM Staging :
Staging is for oral cavity in general. No separate staging for tongue cancers, applicable for
buccal cancers

TX -Primary tumor cannot be assessed

T0 -There is no evidence of primary tumor
T -is Carcinoma is in situ
T1- Tumor is 2 cm or less in greatest dimension
T2 -Tumor is more than 2 cm but not greater than 4 cm in greatest dimension
T3 -Tumor is more than 4 cm in greatest dimension
T4a -Moderately advanced local disease
Tumor invades adjacent structures only (e.g. through cortical bone, [mandible or maxilla]
into deep [extrinsic] muscle of tongue [Genioglossus, hyoglossus, palatoglossus, and
styloglossus],maxillary sinus, skin of face).
T4b- Very advanced local [Link] invades masticator space, pterygoid plates, or skull
base and/or encases internal carotid artery (ICA).
Nx -Regional lymph nodes cannot be assessed
N0 -No regional lymph nodes metastasis
N1 -Ipsilateral single lymph node 3 cm or less in greatest dimension
N2a -Ipsilateral single lymphnode more than 3 cm, not more than 6 cm in greatest dimension
N2b -Ipsilateral multiple lymph nodes, none more than 6cm in greatest dimension
N2c -Bilateral/contralateral lymph nodes, none more than 6 cm in greatest dimension
N3 -Lymph node more than 6 cm in greatest dimensionMetastasis
M0 -No metastasis
M1 -Distant metastasis

STAGING
T1- Stage I
T2 -Stage II
T3 -Stage III
T4a -Stage IV A- Surgically operable cancers
T4b -Stage IV B- Surgically inoperable cancers

Treatment decisions are based on the clinico-radiological staging of the tumor.

Early stage disease (Stage I & II)

• Single modality treatment (Surgery or radical radiotherapy)
• Surgery preferred

Advanced stage disease (Stage III & IV)

• Combined modality treatment
• Surgery followed by Radiotherapy/Chemoradiotherapy
MANAGEMENT:

MEDICAL MANAGEMENT:

 Not have proper medical treatment.

 Only an supportive management like antibiotics, paracetamol.
 Only surgical procedure is applicable for this condition

SURICAL MANAGEMENT:

SURGICAL CONSIDERATIONS
a. Excision of primary Wide local resection of tumor with adequate margins.
1. Resection with clear margin
Assessment of depth of tumor by digital palpation and imaging is an essential
prerequisite for obtaining appropriate deep margin. It is preferable to have a 1 cm clear
margin around tumor in all dimensions at surgery as margins shrink 20-30% after resection.
Any margin less than 5 mm is compromised and warrants adjuvant treatment.
Three treatment modalities are available-
A. Observation
B. Elective neck dissection
C. Elective neck irradiation
A. Observation alone
[Link] with low risk of metastasis (<20 % 1. - T1, tumor thickness < 4 mm, well
differentiated, no LVE, PNI)
2. Early T1/T2 low risk cancer (read above) cancers treated per orally with no violation of the
neck for the approach
3. Patients with reliable follow up
4. Patients with thin neck in whom satisfactory clinical examination is possible
5. Ultrasound negative
B. Elective neck dissection
1. Thick tumor (tumor thickness more than 4 mm)
2. Entry into the neck
3. Cases with unreliable follow up
4. Patients with fat, short neck in whom satisfactory clinical examination is not possible
C. Elective irradiation
1. In cases where primary tumor is treated by radiotherapy
b) Extent of neck dissection
c) Special issues
• Dissection of level IV
ii. Node positive disease
iii. Contralateral neck
C. Reconstruction
i. Primary closure
ii. Skin graft
iii. Local flap
iv. Regional flap
v. Distant flap
vi. Free flap

OTHER MANAGEMENT:

CHEMOTHERAPY
i. Concurrent chemoradiation
ii. Chemotherapy for recurrent/metastatic disease
i. Concurrent chemoradiation
Concurrent chemoradiation is useful either as adjuvant treatment in operable tongue cancer or
as definitive treatment in advanced (inoperable) tongue cancer.
ii. Chemotherapy for recurrent and metastatic disease
The mainstay of the treatment of patients with recurrent/metastatic tongue cancer is
palliation. Pain relief and maintaining the nutrition takes priority in the overall management
of these patients.
Chemotherapy may be offered to patients with good performance status. Before
planning the treatment for recurrent tongue cancer, efforts should be made to identify the
occasional patient who may be candidate for surgical salvage or re-radiation.
1. First line
Palliative chemotherapy is usually a two drug regimen unlike the three drug taxane
based chemotherapy described in the preceding section. The most widely used and
recommended doublet is cisplatinum and 5-flurouracil. The combination of carboplatin and
paclitaxel or docetaxel has been described. The regimen is cisplatin, 5-FU and cetuximab.
Cetuximab is given weekly till the progression of disease.
2. Subsequent line
The outcome of patient failing first line therapy is even poorer. Patients with poor
performance status or those progressing while on first line chemotherapy are best offered
only palliative care.

Radiation therapy

Radiotherapy can be used in the following settings-

1. Primary treatmen
2. Palliative treatment
1. Primary radiotherapy
Radiotherapy can be delivered as external beam radiotherapy (EBRT) alone, brachytherapy
alone or EBRT followed by brachytherapy boost.
a) Brachytherapy alone
Brachytherapy alone is a safe and short duration treatment. It has following
advantages-
• Delivery of high dose is possible in a short period of time.
• Rapid dose fall off towards the periphery allows excellent normal tissue sparing.
• Decreased volume of tissue irradiated leading to better cosmetic result.
iii. Brachytherapy dose
Low dose rate brachytherapy (LDR) 65-70Gy/6-7 days
High dose rate brachytherapy (HDR) 48Gy/12fr 4Gy 1BD x 6 days
b) EBRT alone
EBRT is delivered with megavoltage equipment with 2D conventional, 3D conformal
(3DCRT)radiotherapy or intensity modulated radiotherapy (IMRT).

PATIENT MEDICAL MANAGEMENT:

 [Link] 1GM/IV/BD

 [Link] / 100MG/ IM / BD

 INJ. PARACETAMOL / 1GM / IV/ BD

 TAB. ALPRAX 0.5MG / P/O / HS

 DRUG CHART
S.N NAME OF THE DOSE/ ACTION GROUP SIDE NURSING
O DRUG FREQUENCY/ EFFECT CONSIDERATION
ROUTE

1. INJ. CEFOTAXIME 1gm/BD/IV Inhibits Broad spectrum Head ache, Sensitivity to

bacterial cell antibiotics dizziness, penicillin other
wall synthesis, weakess, cephalosporin.
rendering cell paresthesia, Nephrotoxity :
wall fever, chills, Increased BUN,
0smotically seizure, creatinine, urine
unstable, dyskinesia, output. If notify its
leading to cell nausea, decreasing the
death. vomiting, prescriber may
diarrhoea, indicate
anorexia, nephrotoxicity.
glossitis,
proteinuria,
vaginitis,
pruritis,
leukopenia,
and
pancytopenia.
2. INJ. 50mg/IV/BD H2 histamine Head ache, To assess the GI
RANITIDINE Inhibit receptor dizziness, complaints of
histamine at H2 antagonist sleeplessness, nausea, vomiting,
receptor site in agitation, diarrhoea,.
parietal cells , depression, Assess the mental
which inhibits constipation, status, confusion,
gastric acid diarrhoea, dizziness,
secretion blurred depression, anxiety,
vision, weakness.
vomiting

Not completely Vomoitting, To check intake and

3. 100mg/bd/I.M understood, Analgesic
INJ. TRAMADOL Dizziness, Output chart for
binds to opioid group of drug Headache, decreasing output
receptors hibits Anxiety, may indicate urinary
receptake of Confusion, retension.
nor- Euphoria,
ephinephrine, Seizure, Assess the central
serotonin, does Sedation, nervous system.
not cause Abnormal Changes like;
histamine ECG, dizziness,
release or affect Visual drowsiness, LOC.
heart rate disturbances,
Nausea, Before administering
 Flatulence tramadol
INJ. Emeset 4mg
start to be administer
to the patient, to
prevent from
vomiting.

4.
[Link] 0.5mg/P/O / HS Depresses Benzodiazepin Dizziness, Assess the patient
subcortical e anti-anxiety Confusion, mental status
levels of CNS, ([Link]) Headache, especially in
including limbic Anxiety, geriatric patient prior
system, Depression, to and during
reticular Insomnia, treatment.
formation. Tachycardia,
Hypotension, Assess and monitor
Vomiting, patient blood
Weight pressure.
gain/loss
PRE OPERATIVE NURSING DIAGNOSIS:

 Acute pain related to swelling of inflammatory or disease process as

evidenced by patient verbalisation.
 Impaired breathing pattern related to disease condition as evidence by
decreased oxygen saturation.
 Deficient fluid volume related to excessive salivation as evidenced by
poor skin turgor.
 Imbalanced nutrition less than body requirement related to poor intake as
evidenced by loss of appetite, difficulty in swallowing.
 Risk for metastasis related to disease condition.
 Self care deficit related to poor oral hygiene as evidenced by patient
verbalisation and poor activity.
 Impaired skin integrity related to excessive salivation as evidenced by
poor skin turgor.
 Sleep pattern disturbance related to secretion in mouth as evidenced by
redness of the eyes.
 Knowledge deficit regarding his disease condition as evidenced by
frequent asking question.
 Risk for infection related to hospitalization.
 POST OPERATIVE NURSING DIAGNOSIS:

 Acute pain related to surgical incision as evidenced by pain

scale assessment.

 Deficit fluid volume related to nil per oral as evidenced by poor

skin turgor.

 Imbalanced nutrition less than body requirement related to poor

intake of food as evidenced by patient verbalisation.

 Activity intolerance related to fatigue and surgery as evidence

by needing assistance for activities.

 Disturbed sleep pattern related to pain as evidenced by redness

of the eye

 Deficit knowledge regarding his disease condition as evidenced

by frequent questioning.

 Risk for secondary infection related to hospitalisation.

SUBJETIVE DATA : Patient verbalised that he have pain over the surgical site.
OBJECTIVE DATA : Patient looks dull and tired.

NURSING DIAGNOSIS: Acute pain related to surgical intervention as evidenced by patient verbalisation and pain

scale assessment

GOAL : To reduce the level of pain

PLANNING IMPLEMENTATION RATIONALE EVALUATION

Establish rapport with the To introduce myself so and Improves communication

patient so with the patient. between myself and patient.

Check the vital parameters. Patient verbalised that now

Checked vital parameters.
the pain level is reduced.
Temperature: 98.6*F; Know the patient condition.
And patient looks better.
Pulse:84beats/minute;
Respiration :
28breath/minute;
Blood pressure: 110/80mm
Hg
 Avoid Overcrowded, free
Provide calm environment to environments, open Reduces the anxiety.
the patient. windows, switch on fan,
provided to the patient.

Pain is acute, prickling in

Observe the characteristics
To know the exact location
[Link] Radiating, its in
location,time and radiation of
of pain.
continuous duration.
pain.
1 2 3 4 5 6 7 8 9 10

Provided meditation therapy

Provide diversional therapy
It induce relaxations and
to the patient over 20minutes
to the patient.
divert the mind

[Link] 100mg IV
Administer analgesics as per
Reduce the pain level .
BD is administered to the
physician order.
patient.
 Patient verbalised that now
Evaluate the patient the pain level is reduced. The Know the outcome of the
condition. pain level is 3. nursing care.

1 2 3 4 5 6 7 8 9 10

Temperature: 98.6*F;
Pulse:84beats/minute;
Reassess the patient Know the patient condition.
Respiration :
condition. 28breath/minute;
Blood pressure: 110/80mm
Hg
SBJECTIVE DATA :Client verbalized that, he has not able to take fluid

OBJECTIVE DATA :Client looks dull, present with sunken eyes, dry lips, B.P.90/70 mm of Hg.

NURSING DIAGNOSIS: Fluid volume deficit related to NPO( nil per oral) Evidenced by dry lips, Blood Pressure-
100/70mmof Hg

GOAL : The Patient will maintain normal fluid volume.

PLAN OF ACTION IMPLEMENTATION RATIONALE EVALUATION

[Link] the vital signs. 1. Assessed the vital signs 1. It gives the baseline data for
treatment.
Temp-1000 F,

pulse-120bts/mt, Client and significant

others verbalize
Respiration-32br/mt,
understanding
B.P-90/70 mm of hg. adequate fluid intake
2. Assures adequate amount of intake
2. Assess the hydration 2. Skin turgor is poor. maintained I/O
or lack of fluids.
level. chart ,.monitored orthostatic B.P-
90/70 mm of hg.
Assess the skin turgor.
Monitor I/O chart.

IMPLEMENTATION RATIONALE

PLANNING

Encouraged the patient to take more It helps to promote the fluid level
amount of fluid such as fresh juices,
3. Advice more fluid intake
kanjee, more amount of water as per
DR’S order

[Link] oral care

Induce appetite.

4. Provide oral care. .Explained about average fluid loss

per day.
Helps to motivate client to increase
the fluid intake.
5. Instruct the client about
importance of resting fluid Administered IV fluids.
maintenance levels. DNS- 2 pints and RL. .It meets the fluid volume deficit.

[Link] IV as per the 2 pints/24 hours.

order.

.Maintained I/O chart.

Intake-1800ml It gives account for lack or excess

[Link] and maintain I/O intake.
Output-1200ml
chart.
.Maintained records and report
It helps for documentation
[Link] records and
report
 HEALTH EDUCATION

REGARDING PERSONNEL HYGIENE:

 Advice the patient to Brush your teeth several times each day.

 Advice the patient to Use a soft-bristled toothbrush and gently brush

your teeth several times each day.
 Advice the patient to Rinse your mouth with warm salt water after meals.
 Advice the patient to Make a mild solution of warm water and salt.
 Advice the patient to Rinse your mouth with this solution after each meal.
 Educate the patient to Keep your mouth moistened with water or
sugarless candies.
 Educate the patient to Drink water throughout the day to keep your mouth
moistened.
 Educate the patient to try sugarless gum or sugarless candies to stimulate
your mouth to produce saliva.
 Advice the patient to Choose moist foods.
 Advice the patient to Avoid dry foods.
 Educate the patient to Moisten dry food with sauce, gravy, broth, butter
or milk.
 Advice the patient to Avoid acidic or spicy foods and drinks.
 Advice the patient to Choose foods and drinks that won't irritate your
mouth.
 Advice the patient to Avoid caffeinated and alcoholic beverages.
REGARDING THE KNOWLEDGE OF DISEASE
CONDITION:

 Educate the patient about her disease condition.

 Educate the patient about the complication of her disease
condition.
 Educate the patient about the signs and symptoms of her disease
condition.
 Educate the patient about the treatment modalities of her disease
condition.

REGARDING MEDICATION:

 Educate the patient regarding the drug intake.

 Advice the patient to take the drugs regularly.
 Educate the patient about the side effects of the drugs.
 Advice the patient should not skip the drugs. Advice the
regular follow up care.
 SUMMARY:

[Link] 45 years old male got admitted on 29/09/2015 with the

history of before 2 month patient had swelling of neck is present, pain
over the neck and radiating to back of the neck, vomiting 2 episodes,
fever on and off after collecting the proper history collection and
physical examination, investigations done and diagnosed as tumor in
parotid gland. On 27/09/2015 patient underwent superficial
parotidectomy. Tissue sent to histopathology and diagnosed as cancer
in ACINE CELL CARCINOMA. So the patient referred MMC,
Madurai for further management. And done various investigations
like; Echo, chest X-Rays, MRI neck, USG neck and diagnosed as
mild involvement of nodulae region. So patient underwent for LEFT
COMPLETION OF PAROTIDECTOMY WITH FUNCTIONAL
NECK DISSECTION done on 12/10/2015. Today is 1st POD.

Now patient receives the medication such as [Link] 1gm

IV/BD, [Link] 100mg/ TDS/IV, INJ: RANITIDINE 150mg/
IV /BD, TAB. ALPRAZOLAM 0.5 mg/ P/O /HS and the nursing care
is provided such as back care, IV cannulation, monitoring vital signs,
maintain intake and output chart, administering medication, sterile
dressing over the surgical site and drainage site.
 CONCLUSON:

I have provided possible nursing care to this [Link]

care provided was comprehensive and holistic. This the
very use full for my carrier

I could able to care similar condition in better way. I

thank the faculty for their guidance and support.
 BIBLIOGRAPHY

BOOK REFERENCE:

1. Black, J.M. & Hawks, J.H. (2009). Medical-Surgical Nursing: Clinical

Management for Positive Outcomes (8th ed.). Philadelphia:
Elsevier/Saunders.
2. Hinkle, J.L., & Cheever, K.H. (2014). Brunner & Suddarth’s Textbook of
Medical-Surgical Nursing (13th ed.). Philadelphia: Lippincott Williams &
Wilkins.
3. Ignatavicius, D.D. & Workman, M.L. (2013). Medical-Surgical Nursing:
Patient-Centered Collaborative Care (7th ed.). Philadelphia:
Elsevier/Saunders.
4. LeMone, P., Burke, K.M., & Bauldoff, G. (2011). Medical-Surgical
Nursing: Critical Thinking in Client Care (5th ed.). Upper Saddle River,
NJ: Pearson/Prentice Hall.
5. Lewis, S.M., Dirksen, S.R., Heitkemper, M.M., & Bucher, L. (2014).
Medical-Surgical Nursing: Assessment and Management of Clinical
Problems (9th ed.). St. Louis: Mosby.
6. Academy of Medical-Surgical Nurses. (2012). Scope and Standards of
Medical-Surgical Nursing Practice (5th ed.). Pitman, NJ.
7. Craven, H. (Ed.). (2009). Core Curriculum for Medical-Surgical Nursing.
(4th ed.). Pitman, NJ: Academy of Medical-Surgical Nurses.
8. Pasero, C. & McCaffery, M. (2011). Pain Assessment and Pharmacologic
Management. St. Louis: Elsevier/Mosby.
9. Roberts, D. (Ed.). (2008). Medical–Surgical Nursing Review Questions
(2nd ed.). Pitman, NJ: Academy of Medical Surgical Nurses.
[Link], C., & Cannon, S. (2011). Introduction to nursing research:
Incorporating evidence-based practice. Sudbury, Massachusetts: Jones
and Bartlett Publishers.
 [Link], P. M. (2003). Nursing health assessment: A critical thinking, case
studies approach. Philadelphia, PA: FA Davis Company.
[Link], M. J. & Wilson, D. (2011). Wong’s Nursing Care of Infants
and Children (9th ed.). Philadelphia, PA: FA Davis Company.
[Link], C.  (2012). Physical examination and health assessment (6th
ed). Saunders.

JOURNAL REFERENCE:

1. Landreneau, K., Lee, K., & Landreneau, M. (2010). Quality of life in

patients undergoing hemodialysis and renal transplantation- a meta-
analytic review. Nephrology Nursing Journal, 37(1), 37-45.
2. Nilsson, M., Forsberg, A., Bäckman, L., Lennerling, A., & Persson, L.
(2011). The perceived threat of the risk for graft rejection and health-
related quality of life among organ transplant recipients. Journal Of
Clinical Nursing, 20(2), 274-282. doi:10.1111/j.1365-2702.2010.03388.
3. Yamana, E. (2009). The relationship of clinical laboratory parameters and
patient attributes to the quality of life of patients on hemodialysis. Japan
Journal Of Nursing Science, 6(1), 9-20.

WEB REFERENCE:

1. [Link]
2. [Link]
3. [Link]