CHAPTER I

INTRODUCTION

A. Background of the study

This study focuses on the case of a 15-year-old male client. For confidentiality
purposes, the researchers opted to replace the name of the patient and just call it as
“Client X44”. Client X44 had been admitted at the surgery ward of MCU-FDTMF hospital
on September 03, 2009, with the final diagnosis of Juvenile Nasopharyngeal
Angiofibroma.

Juvenile Nasopharyngeal Angiofibroma (JNA) is a benign tumour of the

Nasopharynx consisting of fibrous connective tissue with various vascular spaces. It is
also histologically benign yet locally aggressive vascular head and neck tumour. JNA
affects almost exclusively adolescent boys, but has been reported in women and elderly
patients on rare occasions. JNA is an uncommon tumour, with reported incidence
between 1 in 5,000 and 1 in 60,000 otolaryngology patients. It is estimated to account
for only 0.5% of all head and neck neoplasms, but is nevertheless considered to be one
of the most common benign neoplasm of the nasopharynx.

The histogenesis and pathogenesis of JNA are unclear. Other suggested

etiologies include trauma, inflammation, infection, allergy, and heredity. Client X44 was
one from those thousands of male adolescents who suffer from this disease.

Frequently, the initial symptoms of this disease are nasal obstruction and
epitasis. Through the years, the treatment of juvenile angiofibroma Includes surgical
excision, electro coagulation, interstitial or external radiation therapy, cryosurgery,
hormone administration and chemotherapy. Radiation, chemotherapy and surgery were
proved the most effective treatments.

The average age at the onset of symptoms is 14 or 18 years, depending on the

series quoted. A typical age range is between 7 and 21 years. Patients are mostly male.
Client X44 is in 2nd year high school, 15 years of age. He is fond of basketball. Every

1
time he plays, he often complains to have shortness of breath due to the obstruction on
the right side of his nose. His hearing sensation were also altered and diminished.

It is important to note the location and where these tumors extend. They
originated in the nasopharynx, specifically near the superior margin of the
sphenopalatine foramen and they occur at the junction of three bones: the palatine
bone, the horizontal ala of the vomer, and the root of the pterygoid process of the
sphenoid.

Since the JNA disease is rare, Client X44 is not aware that he has it. In
accordance to this, he should educate himself to be aware and guard himself with the
knowledge to understand the things that is happening to him.

B. Rationale for choosing the case

Patients with extracranial juvenile nasopharyngeal angiofibroma have a high

likelihood of cure with acceptable morbidity after surgery alone. Transnasal endoscopic
resection is highly successful for selected patients. Patients with intracranial extension,
as well as patients with juvenile nasopharyngeal angiofibroma that recurs after prior
resection, may be treated with either surgery or radiotherapy depending on the
likelihood of achieving a complete resection with acceptable morbidity.

Patients with extracranial juvenile nasopharyngeal angiofibroma are likely to

have a cure with acceptable morbidity after surgery alone. Transnasal endoscopic
resection is highly successful for selected patients. Patients with intracranial extension,
as well as patients with juvenile nasopharyngeal angiofibroma that recurs after prior
resection, may be treated with either surgery or radiotherapy depending on the
likelihood of achieving a complete resection with acceptable morbidity.

The researchers decided to choose the case of a 15 year-old male who was
diagnosed Juvenile nasopharyngeal Angiofibroma mainly because it is rare and most
adolescent boys are not aware of the disease and its symptoms that they tend to take it
for granted. The researchers would like to have deeper knowledge and detailed

2
information about this disease such as the signs and symptoms, different causes,
complications and risk factors, and its medical management and nursing interventions
should be done.

The researchers would also want to have facts about the anatomy and
physiology of the organs involved so that the researchers will be aware about the
systems involved. Furthermore, the researchers would like to be familiar in this kind of
disease, to be able to educate the client about the significant facts about his condition.

C. Significance of the Study

This study aims to educate the following:

Client

Through this case the client will gain more knowledge about his condition and
thus gaining more understanding and eventually will increase the rate of self recovery
and decrease the chance of re-infection.

Individuals

For individual, this case will give them a knowledge and information about the
disease making them alert and aware of their risk factors.

Community

This study will help the community to be alert and aware about this rare disease.
This could help the people in the community to have enough knowledge and skills so
that similar could be prevented and be treated promptly.

Student Nurses

The study will help determine the level of awareness of the student nurse about
the disease and how it occurs. For them to be able to know how to deliver care to
patients with such disease.

3
Clinical Instructor

This study will be an instrument to help asses the learning and the knowledge of the
students, thus, giving them knowledge about the learning needs of the students.

D. Scope and Limitation

The study will focus on the case of a 15 years old male patient who was
diagnosed with Juvenile Nasopharyngeal Angiofibroma and was admitted in Manila
Central University- Filemon D. Tanchoco Medical Foundation hospital particularly in the
surgical ward on September 12, 2009.

The study will stress the signs and symptoms the patient experienced. Also the
study will be including pathophysiology of the disease, its progression and possible
etiology. Nursing management for the disease will also be included.

The study will not thoroughly discuss about the cure for the disease.

4
CHAPTER II

HEALTH HISTORY

A. General History

Patient’s name: Patient X44

Address: Valenzuela City

Date of Birth: May 28, 1994

Age: 15 years old

Sex: male

Nationality: Filipino

Occupation: Student

Civil Status: Single

Religion: Roman Catholic

Date of Admission: September 6, 2009

B. Chief Complaint

“Laging dumudugo ang ilong ko tatlong beses sa isang araw,” as verbalized by

the patient.

C. History of Present Illness

Approximately a month prior to admission at Manila Central University Filemon

D. Tanchoco Medical Foundation. The patient claims that he was hit by his brother on
the nose which resulted to bleeding that was resolve after about 5 minutes.

5
 After the said incident his nose started to bleed every day. Gradually increasing
its frequency to at least three times a day, even at night. Patient also claims that his
visual and hearing acuity decreases gradually, “parang lumalabo mata ko at namimingi
ako” as verbalized by the patient.

Approximately two weeks after he was hit by his brother on the nose, he decided
to seek medical attention. He went to Jose Reyes Memorial Medical Centre, where a
CT scan with contrast and a mass punch biopsy was ordered.

CT scan with contrast revealed:

1. Sinonasal polyps
2. Anthrochoanal polyps
3. Right maxillary ethmoid splenoid sinusitis

Nasal cavity mass punch biopsy revealed fibrous polyps with no malignancy.

He was diagnosed with a paranasal sinus mass angiofibroma with no evidence of

malignancy and was advised to undergo angiography to treat his condition.

Patient went to MCU-FDTMF because of a referral from a relative. Patient was

admitted September 6, 2009. Laboratory Exams like complete blood count, Urinalysis,
Chest X-ray, HBG, Haematology II, and creatinine tests were done as a routine.

All the tests that were done concluded a diagnosis of: Juvenile Nasopharyngeal
Angiofibroma.

Patient underwent surgery September 10, 2009. Patient was endorsed to nursing
students September 15, 2009.

D. Past Medical History

As per procedure, the client was interviewed for his medical history. This is a
routine procedure for the patient’s medical background, and a basis for the physician’s
treatment. Based on the gathered facts, he has completed his basic immunization

6
including BCG, hepatitis, diphtheria, polio and measles. He has never undergone any
operation before. He do not have any known allergies.

E. Family History

Patient is the eldest in the family with just one sibling.

Patient has a history of asthma on his maternal side, while hypertension and
cancer are present on his paternal side. He do not have any family history of cardiac
problem and diabetes. His father is the only smoker in the family.

F. Social History

Patient is a non-smoker and only drinks occasionally (three times a year the
most) he started when he was 12 years old. He claims that he likes to hang out with
friends and eat street food with his friends after school. He is a socially active, have lots
of friends, flexible teenager who likes to read books, cook and a sports aficionado that
he became a varsity player.

G. Physical Assessment

Date of Assessment by: September 15, 2009 (5 days after the surgery)

Vital Signs

Technique Used Findings Interpretation

Temperature Site: Axillary 37.1° c

Respiratory rate Inspection 23 bpm Possibly due to

pain

Pulse Rate Palpation 110bpm Possibly due to

pain

7
Blood Pressure Auscultation 130/90 mmHg Possibly due to
pain

Appearance and Mental Status

Technique Findings Interpretation

used

Height Inspection 5’6

Weight Inspection 54 kg

Body Mass Index

Body Built Inspection Medium body built

Posture Inspection Erect posture when

standing or sitting

Hygiene and Inspection Clean, neat

overall grooming

Body and Breath Inspection No Significant body

odor or breath odor

Attitude Observation Cooperative, able to

follow Instruction

Mood Observation Appropriate to

situation; not irritated

Speech Observation Understandable,

moderate pace, clear
tone and inflection;
exhibits thought

8
 association

Relevance and Observation Logical sequence;

Organization of makes sense; has
thoughts sense of reality

Skin

Technique Findings Interpretation

used

Skin Color Inspection Brown

Uniformity of Skin Inspection Generally uniform

color except in areas
exposed to the
sun and areas of
lighter
pigmentation
(palms, lips, nail
beds)

Skin Temperature Palpation Uniform; within

normal range

Skin Lesions Inspection No significant

lesions; birthmark
on the back of
right shoulder;

Breaks in the skin Inspection surgical incision

with suture on the
face and right side

9
 of the neck

Presence of Inspection; No edema

Edema palpation

Skin moisture Inspection; Moisture in the

palpation axillae

Skin turgor Inspection; Skin quickly

palpation springs back to
previous state
when pinched

Hair and Nails

Technique Used Findings Interpretation

Evenness of Inspection Evenly distributed

growth over the hair
scalp

Thickness or Inspection Thick hair

thinness

Hair texture Inspection; Dry hair, Dandruff Possibly due to

palpation frequent sun
exposure

Presence of Inspection No infection or

infection or infestation
infestation

Amount of body Inspection More hair present

hair in axillae and legs

10
 than in the rest of
the body

Nail curvature Inspection Convex curvature

no evidence of
clubbing

Fingernail and palpation Smooth

Toenail texture

Fingernail and Inspection pinkish

Toenail bed color

Blanch test of Inspection; Blanch when

capillary refill palpation pressed but
quickly turn pink
when releases
(approximately not
more than 1 sec.)

Head and face

Technique used Findings Interpretation

Presence of Palpation Smooth; absence

nodules, masses of nodules
or depression on masses or
the head depression

Facial Lesions Inspection Surgical Incision

on the right side of
the face, lateral to
the nose

11
Facial symmetry Inspection symmetrical

Symmetry of facial Inspection Symmetrical facial

movement movements

Eyes and Visual Acuity

Technique used Findings Interpretation

Eyebrow Inspection Hair evenly

distributed and
symmetrically
aligned; skin
intact; equal
movement

Eyelashes Inspection Evenly Distributed;

curled slightly
outward

Eyelids Inspection Skin intact; no

discoloration; lids
close
symmetrically;
bilateral blinking

Bulbar Inspection Transparent with

Conjunctiva white sclera

Palpebral Inspection Shiny and pink

Conjunctiva

Surrounding Inspection; No edema

area of the

12
orbit palpation

Reaction to Inspection One pupil constrict

light when illuminated
and the other one
constrict at the
same time even if
not illuminated
(equally reactive)

Peripheral Inspection When looking

visual fields ahead client see
objects in the
periphery

Visual acuity Inspection Patient not able to Due to the pressure

read the student that was exerted by
nurse’s name the previously
plate within removed tumor
approximately 1.5
meter

Ears and Hearing

Technique used Findings Interpretation

Color Inspection Same as facial

skin

Symmetry Inspection symmetrical

Pinna Inspection; Mobile, firm, pinna

palpation recoils after being

13
 fold

Hearing Acuity Inspection Patient able to

respond to
questions asked in
a normal voice
tones

Nose

Technique used Findings Interpretation

Color Inspection Same as facial

skin

Symmetry Inspection Symmetrical

Lesions, scars, Inspection; With surgical

cuts palpation incision on the
right side

Patency of nasal Inspection No evidence of

cavities nasal flaring.

Discharges Inspection No discharge

Smelling ability Inspection Able to distinguish

different smell

14
Mouth and Throat

Technique used Findings Interpretation

Outer lip Inspection; Pink color, soft,

palpation moist, smooth
texture;
symmetrical, have
the ability to purse
lips

Inner Lip Inspection; Pink, smooth, soft,

palpation glistening

Teeth Inspection Missing left upper

pre molar

Gums Inspection; Moist, pink, firm

palpation

Tongue Inspection; Central position,

palpation pink, no lesions

Tongue Inspection Moves freely

Movement

Base of the Inspection; Smooth with

Tongue palpation prominent veins

Hard and soft Inspection Light pink color of

palate soft palate; lighter
pink hard palate

uvula Inspection Pinkish;Positioned

in midline soft
palate

15
Tonsils Inspection Pink, no swelling

Gag reflex Inspection; Present

palpation

Neck

Technique used Findings Interpretation

Neck muscles Inspection; Muscles equal in

Palpation size in both
sides; head
centered

Head movement Inspection Discomfort when Due to the surgical

moving the head incision on the right
laterally on the side of neck
right side
towards the
shoulder and
when head is
turned right and
left.

Lymph Nodes palpation Not palpable

16
Trachea Inspection; Central
palpation placement in
midline of neck

Thyroid Gland Inspection; Ascends during

palpation swallowing

Thorax

Technique used Findings Interpretation

Skin Inspection Uniform in color

Temperature Palpation Uniform; same as

in the rest of the
body

Shape and Inspection Symmetrical

Symmetry

Spinal Alignment Inspection; Spine vertically

(posterior thorax) palpation aligned

Respiratory Inspection; Full and

Excursion Palpation symmetric chest
(posterior thorax) expansion

Breathing patterns Inspection; Rhythmic and

auscultation effortless
respirations;
resonant sounds

Respiratory Inspection; Full and

17
Excursion(anterior Palpation symmetric chest
thorax) expansion

Abdomen

Technique used Findings Interpretation

Skin Inspection Uniform in color

Temperature Palpation Uniform; same

as in the rest of
the body

Contour and Inspection; palpation No evidence of

Symmetry enlargements of
organs,
symmetric
contour

Abdominal Inspection; palpation Symmetric

Movements movements
caused by
respirations

Bowel Sounds Inspection; Audible bowel

Auscultation sounds
;frequency within
normal range

Bladder Inspection; palpation Not Palpable

18
Upper extremities

Technique used Findings Interpretation

Skin Inspection Slightly darker in Due to sun

color than the rest exposure
of the body; no
lesions

Temperature Palpation Uniform; same as

in the rest of the
body

Contraptions Inspection IV canulla inserted

(gauge#18) for
D5LR type of IV
fluid

Presence of mass/ Inspection; No edema, no

edema palpation bulges

Range of motion Inspection Moves freely; full

range of motion

Lower extremities

Technique used Findings Interpretation

Skin Inspection Slightly darker in Slightly darker

color than the rest skin to sun
of the body; some exposure; scars
scars, no lesions due to past minor
injuries

19
Temperature Palpation Uniform; same as
in the rest of the
body

Contraptions Inspection No contraptions

Presence of mass/ Inspection; No edema, no

edema palpation bulges

Range of motion Inspection Moves freely

H. Patterns of Functioning

Date of Assessment: September 15, 2009 (5 days after the surgery)

Method of Assessment used: Observation, Interview

Findings
Activities and Rest Patient X44 has complaints about his
sedentary condition in the hospital he
claims to be bored in the hospital. He is
getting more than enough rest as well

Circulation Pulse is present in all pulse sites. Pulse

can be felt with moderate pressure of the
finger. Pulse Rate during assessment is
110 bpm, blood pressure is at
130/90mmHg
Ego Integrity Patient verbalized: “nakakahiya yung
peklat ko” which manifest a decreased self
esteem

20
Elimination Patient defecates once a day with formed,
brown in color stool. He also urinates
regularly with clear to light yellow urine.
His input and output is being closely
monitored which reveals no significant
imbalance.
Food and fluid Client X44 is on a Nothing per Orem diet.
He is in strict fluid intake and output
monitoring, in our 6-hour shift he has taken
in 520 ml of fluids which is being
supplemented by her intravenous fluid of
5% Dextrose in Lactated Ringers infusing
at 15-16 drops per minute.

Hygiene Patient is on complete bed rest with

bathroom privileges. He is able to take a
bath every day except on the head to
avoid the surgical site. During physical
examination patient exhibits a clean
presentation of himself with clean body,
short clean finger and toe nails. There
was no significant body odor.
Neurosensory Patient is conscious, alert and coherent.
Assesment of the functions of the cranial
nerves was done which reveal no
significant deviation
Pain and Discomfort During assessment patient complains of
radiating pain in his surgical site, with pain
scale of 8/10. There was also a slight
elevation on his blood pressure, pulse rate

21
 and respiratory rate which may be possibly
due to his pain.
Respiration Patient do not have any complains about
his breathing. His respiratory rate is 23
bpm which is within normal range.
Safety The patient has no known allergies. He
always have a bed side assistant from his
family and staff nurses to ensure his
security.
Sexuality The patient is not sexually active. Patient
claims that he has a girlfriend at school,
which manifest the patient’s sexual
orientation.
Social Interaction Patient has a normal social interaction as
manifested by the way he communicates
with health care providers.
Teaching and Learning Patient is able to comprehend health
teachings that are being taught to him,
including teachings about his medication
and how to take care of his incision site.

I. Impression/Medical Diagnosis

Juvenile Nasopharyngeal Angiofibroma

22
 CHAPTER III

DISCUSSION OF THE DISEASE

A. Anatomy and Physiology

Respiratory System

Nostrils –

The nose is covered with skin and it’s supported internally by bone and cartilage. Its two
nostrils provide openings through which air can enter and leave the nasal cavity. These
openings are guarded by numerous internal hairs, which help prevent the entrance of
relatively large particles sometimes carried in the air

Nasal Cavity –

A hollow space behind the nose is divided medially into right and left portion by the
nasal septum. The nasal cavity warms, humidifies, and filters the air you inhale,
protecting the delicate tissues within the lung.

Pharynx –

Pharynx (throat) is located behind the oral cavity and between the nasal cavity and the
larynx. It functions as a passageway for food traveling from the oral cavity to the
esophagus and for air passing between the nasal cavity and the larynx. It also aids in
producing the sound of speech

Nasopharynx –

23
is the uppermost part of the pharynx. It extends from the base of the skull to the upper
surface of the soft palate

SKELETAL SYSTEM

Frontal Bone –

Forms the forehead, the bony projections under the eyebrows, and the superior part of
each eye’s orbit.

Parietal Bones –

Form most of the superior and lateral walls of the cranium

Occipital Bone –

Forms the floor and back wall of the skull

Sphenoid Bone –

The butterfly-shaped sphenoid bone spans the width of the skull and forms part
of the floor of the cranial cavity.

Ethmoid Bone –
Very irregularly-shaped and lies anterior to the sphenoid. It forms the roof of the
nasal cavity and part of the medial walls of the orbits

Superior and middle conchae – form part of the lateral walls of the nasal cavity
and increase the turbulence of air flowing through the nasal passages.

24
 Modifiable factors: Non-modifiable factors:
-diet -Age (7-19 y/o, peak age of 15 B. Pathophysiology of
-↑ intake of grilled foods y/o)
-↑ intake of preserved -Gender (M>F) the Disease
foods
-environment
-inhalation of sidestream smoke

↑ benzopyrines ingestion in ↑ nitrosamines ingestion in

the body the body

Damage in the structure of deoxyribonucleic acid (DNA)

Cell’s check point is intact Cell’s check point is by passed;

Cell cycle clock functions (Cell cycle clock malfunctions)

Activation of tumor suppressor gene

(p53 gene that is found in chromosome 17)
apoptosis Chromosome Non-reciprocal combination of
fusion the genes
Proliferative arrest of the damaged DNA

DNA can be repaired DNA cannot be Mutation ofp53 and HER2/neu gene
repaired (Genomic instability)

Repair of damaged DNA P53 gene will instruct

the cell to undergo
death Activation of growth promoting oncogene Alterations in the
Cellular and genomic stability (HER2/neu gene) genes that regulate
Cell apoptosis apoptosis (p53 gene)
Stimulation of hermatomatous tissue growth

↓ apoptosis
Next page 25
(page 2)
 Anterior invasion: CXR result:
the tumor pushes the Antral blowing sign
page 2 posterior wall of
maxillary sinus forward

Hermatomatous tissue production will exceed physiologic demand
lateral invasion:
the tumor pushes the
Hermatomatous tissue hyperplasia posterior wall of
maxillary sinus forward
Physical examination finding
during admission:
Bulging of the cheek

Tumor cells will undergo progressive cell proliferation

accompanied by further development of a heterogenous tumor extends on the
cell population posterolateral wall of
(growth of primary tumor) nasal cavity.

JUVENILE NASOPHARYNGEAL Downward displacement

of the eyeball
ANGIOFIBROMA Tumor exerts pressure on
Orbital proptusion the tiny blood vessels in
Will grow and central tumor cells will become hypoxic the mucous membrane of
nasal cavity
superior invasion:
Tumor cells will secrete angiogenic growth factor that will bind tumor expands into the
to specific receptors on endothelial cells orbit via inferior orbital
Rupture of blood vessels
fissure and then to the
superior orbital fissures
Endothelial cell proliferation
epistaxis
Nasal obstruction
Invasion and capillary tube formation
page 3

26
 page 3

If treated If untreated

Medical Management
Facial and nerve compression Continuous proliferation of
>Medications hermatomaous tissue
>Tramadol
>Oxacillin Facial paralysis
>Prixine ↑ blockage of nasal cavity

>IVF: D5 LR to run for 8 hrs.

Complete blockage of the nasal
Surgical management cavity
>External Carotid Artery Ligation; Excision of intranasal mass
Legend:
via transpalatal approach
↑CO2 ↓O2
if untreated

Respiratory acidosis
if treated

Physical examination finding during

Organ dysfunction
Recovery admission

Laboratory findings Multiple Organ dysfunction

syndrome

Diagnosis DEATH

27
 C. Drug Study

MEDICATION MECHANISM OF INDICATION CONTRAINDICATION NURSING

DOSAGE
ACTION RESPONSIBILITIES

Oxacillin -Bactericidal: Inhibits > Infection due to > Contraindicated to o Culture

cell wall of sensitive penicillinase-producing allergies with infection before
Classification: 500 mg via IV, every 6
organisms, causing staphylococci; may be penicillins, treatment; re-
hours
Antibiotic, cell death used to initiate cephalosporins or culture if
treatment when a other allergens response is not
Penicillinase
staphylococci infection as expected
> Use cautiously with
is suspected o Continue
renal disorders,
therapy for at
pregnancy, lactation
least 2 days
after infection
has been
disappeared,
usually 7-10
days.

Patient Teaching:

28
 o Tell the patient
that he may
experience this
side effects:
Upset stomach,
nausea,
diarrhea, mouth
sores and pain
at the injection
site
o Report DOB,
rashes, severe
diarrhea severe
pain at the
injection site
and mouth
sores.
Tramadol -Binds to mu-opioid >Relief of moderate to > Contraindicated with o Re-assess
receptors and inhibits moderately severe allergy to tramadol or patient’s level of
(Ultram) 300 mg in PNSS 500
the reuptake of pain opioids or acute pain at least 30
cc, every 4 hours
Classification: norepinephrine and intoxication with minutes after
serotonin alcohol, opioids or administration

29
Analgesic -Cause many effects psychoactive drugs. o Monitor CV and
similar to opioids- respiratory
> Use cautiously in
dizziness, status. Withhold
pregnancy, lactation,
somnolence, nausea, dose and notify
seizures, concomitant
constipation-but does the prescriber if
use of CNS
not have the respirations
depressants, renal
respiratory depressant decrease or
dysfunction or hepatic
effects. rate is below 12
impairment.
bpm.
o Monitor bowel
and bladder
function. An
anticipate need
for laxative.
o For better
analgesic
effect, give drug
before onset of
intense pain
o Monitor patients
at risk for
seizures. Drug

30
 may reduce
seizure
threshold.
o Monitor patient
for drug
dependence.
o Withdrawal
symptoms may
occur if drug is
stopped
abruptly.
Reduce dosage
gradually.

Patient Teaching:

o Tell patient to
take drug as
prescribed and
not to increase
dose or dosage
interval unless

31
 ordered by the
prescriber.
o Caution
ambulatory
patient to be
careful when
rising and
walking. Warn
out patient to
avoid driving
and other
potentially
hazardous
activities that
require mental
alertness until
drug’s CNS
effects are
known.
o Advise patient
to check with
prescriber

32
 before taking
OTC drugs
because
interactions can
occur.
o Warn patient
not to stop the
drug abruptly.
Drixine -Thought to cause > Nasal Congestion > Contraindicated in o Monitor patient
local vasoconstriction patients hypersensitive for rebound
Classification: 2 gtts, TID x5 days
of dilated arterioles, to this drug and in congestion or
Nasal Drugs reducing blood flow children younger than systemic effects
and nasal congestion 6 years old o Don’t give to
children
> Use cautiously in
younger than 6
patients with
years old
hyperthyroidism,
cardiac disease,
hypertension or Patient Teaching:
diabetes mellitus.
o Teach patient
> Use cautiously in how to use the
patients with difficulty drug. Tell him to

33
urinating because of hold head
an enlarged prostate. upright to
minimize
swallowing of
drug and to sniff
spray briskly.
o Caution patient
not to share
drug because
this could
spread infection
o Tell patient not
to extend the
recommended
dosage and to
use only when
needed.
o Inform patient
that prolonged
use may result
in rebound
congestion.

34
 D. Diagnostic/Laboratory Exams

Complete Blood Test

NORMAL
COMPONENTS RESULTS IMPRESSION
VALUES

Decrease oxygen level possibly due to

Hemoglobin 14-18 mg/dl 13 mg/dl poor oxygenation and also possibly due to
blood loss during nose bleeding.

Hematocrit 40-50% 40% Normal

Higher compared to the normal

Neutrophils 54-62% 64%
percentage rate. Possibly due to infection

Eosinophils 1-3% 3% Normal

Basophils 0-0.75% 0 Normal

Lymphocytes 25-33% 26% Normal

Urinalysis
Color: yellow
Clarity: Slightly hazy
Specific Gravity: 1.010

Chemical Analysis Result

pH 6.5

CHON Negative

CHO Negative

Blood Negative

Ketone Negative

Nitrite Negative

35
Bilirubin Negative

Urobilinogen 0.2 EU/dL

Leukocytes Trace

Serum Creatinine – September 6, 2009

Component Result Normal Values

Creatinine 0.7 0.5-1.3mg/dL

Hematology II – September 6, 2009

Component Result Normal Values

Phosphorus 3.1 mg/dL 2.7-4.5 mg/dL
Calcium 9.6 mg/dL 8.8-10.2 mg/dL
Potassium 4.2 mg/dL 3.5-5.1 mg/dL
Sodium 140 mmol/L 136-145 mmol/L

Radiologic Findings
Date Done: September 8, 2009
Lung Fields are clear
Heart is not enlarge
Both hemidiaphragms and Costophrenic sulci are intact.

Impression: Normal Chest

Interpretation
Results shows that the patient have a normal chest.

Operating Room Record

Date Done: September 10, 2009

36
Pre-Operative and Operative Diagnosis: Intranasal Mass Right DC Juvenile
Nasoangiofibroma s/p External Carotid Artery Ligation

Type of Operation: External Carotid Artery Ligation, Excision of Intranasal Mass Via
Transpalatal Approach

Anesthesia: General

Operation started: 9:50 am Operation ended: 11:00 am

Specimen removed: S. out = 10:30am (Angiofibroma)

Pre-anesthetic evaluation:

CXR: Lung field are clear, heart is not enlarge,

Pathology Consultation Report (Routine Examination)

Date Done: September 11, 2009

Specimen: Angiofibroma

Location: Right maxillary, frontal, ethmoid & splenoid sinusitis

Staging:

Stage II – Invade pterygomaxillary fosa, paranasal sinuses with bony destruction.

Findings – Gross:

Specimen designated as “Naso angiofibroma” consists of two tan to light brown

irregular, firm tissue measuring 5.5x1.7x0.8 cm and 6.0x3.0 cut sections shows tan
finely granular surfaces.

Interpretation:

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Type of masses of fibrous tissue containing many thin wall blood vessels. Intranasal
Mass Right DC Juvenile was found. Polyps are not detected as malignant. Therefore is
not afflicted with cancer. Stage II Invade pterygomaxillary fosa, paranasal sinuses with
bony destruction.

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CHAPTER IV
NURSING PROCESS

A. Long Term Objectives

 Prevent development of infection in the surgical wound by teaching the client
proper wound care.
 Assist patient in gradual adaptation of his poor body image.
 Decrease the chance of the reoccurrence of the disease by teaching client to
have a proper diet and healthy lifestyle.
 Maintain follow up check up with healthcare provider.
 Avoid polluted air to prevent complication in the post operative site.

B. List of Problems

List of Problems gathered during assessment dated: September 15, 2009

Problems Nursing Diagnosis

Radiating Pain in the nasal area Acute Pain related to Surgical Incision
Risk for infection Risk for Infection
Concerns regarding appearance Anxiety related to disturbed body image
secondary image
Dry hair, Dandruff Self Care deficiency

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 C. Nursing Care Plan

PROBLEM NURSING RATIONALE OBJECTIVES OF NURSING RATIONALE EVALUATION

DIAGNOSIS CARE INTERVENTION

Acute Pain Acute pain related Incision on the After 30 minutes of Independent After 30 minutes of
to the presence of right side of the nursing nursing
inflammation at the neck intervention, the intervention, the
Subjective cues: suture site as patient will be able Support head and Muscle weakness patient was able to
Trauma
manifested by to decrease neck with pillows. results from decrease
“Masakit yung tahi
facial grimace, perception of pain Show client how to muscle and nerve perception of pain
ko sa leeg” as
discomfort at the as manifested by support neck resection in the as manifested by
verbalized by the Cell lining damage
surgical site, pain scale level of during activity. structures of the pain scale level of
patient.
restlessness, 3/10 and absence neck. Lack of 3/10 and absence
inflammation and of facial grimace, support aggravates of facial grimace,
Activation of
redness of excision restlessness and discomfort and restlessness and
Objective cues: Inflammatory
site, irritable and irritability. may result to irritability. Goal Met
Process
 Facial pain scale grade of dehiscence of the
grimace. 7. suture area.
 Discomfort at
Production of
the surgical
prostaglandin
site. Provide comfort Promotes
 Restlessness measures by relaxation and

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 Inflammation Stimulation of placing the patient helps client refocus
and redness nociceptors into supine position attention on
of incision and providing something besides
site. diversional self/discomfort.
 Irritable. Perception of pain activities such as May reduce
 Pain scale watching analgesic dosage
grade of television, visiting needs.
7/10. and reading.

Encourage client to
Swallowing causes
expectorate saliva
muscle activity that
or to suction mouth
may be painful
gently if unable to
because of strain
swallow.
on suture lines.

Note nonverbal
Aids in determining
indicators and
presence of pain,
autonomic
need for
responses to pain.

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Evaluate effects of effectiveness of
analgesic. medication.

Medicate before May enhance

activity/ treatments cooperation and
as indicated. participation in
therapeutic
regimen.

Recommend use
Promotes sense of
of stress
well being, may
management
reduce analgesic
behaviours ex.
needs and
relaxation,
enhance healing.
techniques, guided
imagery.

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Dependent

Recommend use Analgesics inhibit

of analgesic synthesis of
(Tramadol 300mg prostaglandin in
via IV q 4 hours) the CNS.

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 Problem Nursing Rationale Objectives of Nursing Rationale Evaluation
Diagnosis Care Intervention
Independent

Risk for wound Risk for infection Mass growth inside Within the time of Maintain surgical To prevent the After 7 days of
infection related to break in the nasal area wound healing aseptic technique invasion and nursing
the skin related to (approximately 7 in cleaning and multiplication of intervention the
surgery days), the patient dressing the microorganisms patient did not
Excision of the will be able to surgical wound. manifest swelling,
Objective Data: mass by surgery manifest no sign of redness, pain and
Break in the skin infection on the inflammation in the
due to incision surgical site Observe and With the onset of wound. The
wound Open wound/ report signs of infection, the wound appeared
break in the skin infection such as immune system is dry and in the
redness, warmth, activated and signs healing process.
discharge and of infection appear
Exposure to increase body
infectious agents temperature -Goal met

Encourage Protein promotes

Risk for infection balance diet, Eat tissue repair and
food rich in protein wound healing

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 and Vitamin C while Vitamin
intake enhances the
immune system.

Encourage Tissue repair is at

adequate rest and its peak when we
sleep sleep.

Practice range of To promote better

motion exercises circulation, thus
delivering more
blood and nutrients
to the body to
enhance tissue
repair

Use proper hand Hand washing

washing significantly
techniques before decreases the

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 and after giving number of
care to patient, pathogens on the
anytime hands skin and
become soiled, contributes to
even if gloves are decreases in
worn. patient’s morbidity
and mortality

Dependent

Administer To eradicate all

Oxacillin 500 mg microorganisms
via IV, q 6 hours, that may invade
as ordered by the the surgical site
physician.

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 PROBLEM NURSING RATIONALE OBJECTIVES OF NURSING RATIONALE EVALUATION
DIAGNOSIS CARE INTERVENTION

Anxiety After 2 days of Independent After 2 days of

nursing nursing
Mass growth in the
intervention the intervention the
nasal area
Subjective cues: Anxiety related to patient will Discuss meaning Aids in identifying/ patient manifest a
disturbed body manifest a of change with defining the decrease in the
 “Ang pangit
image secondary decrease in the patient, identifying problems to focus magnitude of
ng tahi ko Excision of mass in
to surgery. magnitude of perceptions of attention and client’s anxiety as
sa the nasal area/
client’s anxiety as current interventions manifested by :
leeg..mawa surgery
manifested by : situation/future constructively.
wala pa ba  Patient
expectations.
ito?” as  Patient being able
verbalized suture in the neck being able to look at
by the and face to look at the mirror
Note emotional
patient. the mirror Client may  Decreased
reactions.
 Patient  Decreased experience frequency in
verbalizing Alteration on frequency in immediate verbalizing
his anxiety physical verbalizing depression after his anxiety
regarding appearance his anxiety surgery or react regarding
his image regarding with shock and his image
frequently his image denial. Acceptance
Goal Met
(almost Anxiety of changes cannot
everytime be forced, and the

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 student grieving process
nurse enters needs time for
patient’s resolution.
room)

Objective cues: Maintain clear,

May help allay
reassuring
Patient refrains patient from fears
manner.
from looking of dying,
Acknowledge and
himself at the suffocation and
accept expression
mirror. inability to
of feelings of grief,
communicate, or
hostility.
mutilation.

Encourage
Expression of
identification of
concern brings
anticipated
problems into the
personal/ work
open where they
conflicts that may
can be examined
arise.
or deal with.

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Collaborative

Refer client for A multifaceted

counseling. approach is
required to assist
client toward
rehabilitation and
wellness.

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 D. Course in the Ward

On September 15, 2009, Patienttx44 admitted at the surgery ward. PatientX44

is monitored for post operational complications. The patients vital signs are taken and
recorded as follows T=37.1 C, BP=130/90mmHg, RR=25cpm, PR=110bpm. With
ongoing intravenous fluid of D5 Lactated Ringer’s regulated at 15-16gtts/min hooked at
the right arm. Report of pain was recorded.

On September 16, 2009, Received patient on bed awake and smiling with
ongoing intravenous fluid of D5 Lactated Ringer’s regulated at 15-16 gtts/min. Hooked
at the right arm .Vital signs are taken and recorded as follows T=37.3 C ,
BP=110/80mmHg ,RR=25cpm ,PR=102bmp . Morning care facilitated.

E. Discharge Planning

Medication
The client should continually be provided with needed medication. Co Amoxiclav
375mg 1tablet TID for 7days, Loratidine (Antihistamine) 10mg 1 tablet OD, Drixine
2gtts TID for 5 days. Patient should take the medication as prescribed.

Exercise And Activities

The client should be encouraged to have an adequate rest to prevent fatigue and
other complications of the disease. Inform the client to avoid lifting heavy objects to
avoid increased pressure to operative site that may lead bleeding and evisceration.
Avoid blowing his nose. Advice range of motion exercises.

Treatment

The client’s Juvenile nasopharyngeal angiofibroma has already been treated

through surgery for better ventilation and excretory function of the respiratory system.

Instruct the patient to practice surgical aseptic technique in cleaning and dressing
the wound.

Health Teachings

· Discuss the importance of visiting healthcare provider regularly for follow-up

repetition of symptoms and infection that is non-responsive to treatment.

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· Teach the client the importance of creating a healthy habits and lifestyle like eating
nutritious food.

· Instruct his to report severe cramping, heavy bleeding, or hot flashes to his doctor
immediately that may be symptomatic of complications of post-operative wound.

· Inform the client to drink moderate amount of fluid, to prevent fluid volume deficit.

· Instruct client to check mouth and nose daily and report redness, purulent
drainage or discharge.

· Teach the client how to clean the suture properly to avoid contamination of the
wound and transfer of microorganisms.

· Report mouth and nose discharge, excessive bleeding, redness or pain, or

elevated temperature to healthcare professional promptly.

Out Client Consultation

The client and/or the family member should be aware of the available community
groups and other organizations to provide support, assistance and education to family
regarding the needs of the client.

Follow-up check up in the ENT OPD should be done to determine whether the
infection is still present.

Diet

The client should be encouraged to increase fluid intake to avoid dehydration

and to choose foods that are appealing to his taste to stimulate appetite but following
the low salt, low fat diet. The client is also encouraged to take well-balanced diet
increased vitamins A, C, E and Folic acid intake, as well as fruits and vegetables. The
client should avoid eating grilled and preserved foods.

Spiritual Counselling

Tell the patient about the immeasurable power of prayer, no matter what the
patient’s religion is. Encourage him to visit his place of worship if tolerated.

“I can do all things through Christ to strengthen me”,

- Holy Bible

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