I. Basic Facts:
Patient Name: A.H
Age: 61 Sex: Female
Admission Date: 11/23/09
Medical Diagnosis: Basal Cell Carcinoma

II. Anatomy and Physiology:
In mammals, the skin is the largest organ of the integumentary system made up of multiple layers of ectodermal tissue, and guards the underlying muscles, bones, ligaments and internal organs. All mammals have skin because it interfaces with the environment and plays a major role by being anatomical barrier in protecting the body from pathogens and prevention of excessive fluid loss. Its other functions are insulation, temperature regulation, sensation, and the protection of vitamin B folates. The skin also has the ability to absorb nitrogen and carbon dioxide by diffusion into the epidermis in small amounts. The skin is divided into three layers; the epidermis, which provides waterproofing and serves as a barrier to infection; the dermis, which serves as a location for the appendages of skin; and the hypodermis (subcutaneous adipose layer).
Epidermis is divided into several layers where cells are formed through mitosis at the innermost layers. They move up the strata changing shape and composition as they differentiate and become filled with keratin. They eventually reach the top layer called stratum corneum and are sloughed off, or desquamated. This process is called keratinization and takes place within weeks. The outermost layer of the epidermis consists of 25 to 30 layers of dead cells. The dermis is the layer of skin beneath the epidermis and is composed of connective tissue and cushions the body. It contains the hair follicles, sweat glands, sebaceous glands, apocrine glands, lymphatic vessels and blood vessels. The blood vessels in the dermis provide nourishment and waste removal from its own cells as well as from the Stratum basal of the epidermis. Finally the hypodermis, which is not a part of the skin but like its name meaning, it lies directly beneath the skin. Its purpose is to attach the skin to underlying bone and muscle as well as supplying it with blood vessels and nerves.

III. Pathophysiology:
Basal cell carcinomas develop in the basal cell layer also known as the stratum germitavium of the skin. Sun light exposure leads to the formation of thymine dimers, a form of DNA damage. While DNA repair removes most UV-induced damage, not all crosslink’s are excised. There is, therefore, cumulative DNA damage leading to mutations. Apart from the mutagenesis, sunlight depresses the local immune system, possibly decreasing immune surveillance for new tumor cells. According to Skin Cancer Foundation, there are approximately 800,000 new cases yearly in the United States alone. Up to 30% of caucasians develop basal cell carcinomas in their life time. Most sporadic BCC arises in small numbers on sun-exposed skin of people over age 50, although younger people may also be affected. The development of multiple basal cell cancer at an early age could be indicative of Nevoid basal cell carcinoma syndrome.
Basal cell carcinoma is the most common skin cancer. It occurs mainly in fair-skinned patients with a family history of this cancer. Sunlight is a factor in about two-thirds of these cancers; therefore, doctors recommend sun screens. One-third occurs in non-sun-exposed areas. Basal cell cancer is the most common skin cancer. It is much more common in fair-skinned people with a family history of basal cell cancer. The incidence of contracting the cancer is higher in people who live closer to the equator or at higher altitude. Some signs are when patient’s skin presents a shiny, pearly nodule. However, superficial basal cell cancer can present as a red patch like eczema. Infiltrative or morpheaform basal cell cancers can present as a skin thickening or scar tissue - making diagnosis difficult without using tactile sensation and a skin biopsy. It is often difficult to distinguish basal cell cancer from acne scar, actinic elastosis, and recent cryodestruction inflammation. To diagnose basal cell carcinomas, a skin biopsy is taken for pathological study. The most common method is a shave biopsy under local anesthesia. Most nodular basal cell cancers can be diagnosed clinically; however, other variants can be very difficult to distinguish from benign lesions such as intradermal nevus, sebaceomas, fibrous papules, early acne scars, and hypertrophic scarring.

IV Medical Orders:
Standard surgical excision
Mohs surgery
Chemotherapy: Imiquimod 5x wks for 6 wks
Radiation
Photodynamic Therapy
Cryosurgery
There are currently no links between the link of diets and BCC. Though new research has found information that vitamin d may affect this cancer.

V. Developmental Level:
Middle adulthood: 45 to 65 Generatively VS. Stagnation
My patient is at the stagnate level due to the fact that they were unable to participate in their community. Though the disease BCC has been encounter by my patient, there are no findings that link the disease to the stagnation.

VI. Maslow’s Hierarchy of Needs:
My patients current level on the hierarchy is physiologic due to the inability to ambulate. But if it was rated solely on the disease then she would fall under the esteem level. This due to the blemishes that is present on the surfaces areas of the body. She constantly talked about how she used to look when she was younger before she was diagnosed with the cancer. She finds difficulty in talking to other residents because of the fear of the unknown.

VII. Nursing Care Plan:
Nursing Diagnosis: Pain R/T Lesions
Goal: Severity of pain will decrease in 1 shift.
Interventions: Assess pain using the pain scale.
Intervention 2: Provide nursing comfort measures such as back rubs, to decrease pain.
Rationale: Pain is subjective data and should be addressed promptly.
Evaluation: The nursing interventions 1 and 2 were successful in the decrease of pain. Pt states that “pain went from a 7 to a 2 on the pain scale.”

VIII. Teaching Plan:
As a nurse you would like the patient to know that after the cancer has been removed they should be on the lookout for the reoccurrence of any lesions.