IJNHCR

Introduction

According to the most recent national statistics, malignant tumor/neoplasm is the leading cause of death in Taiwan. One such neoplasm, non-Hodgkin’s lymphoma, is the ninth most common cause of cancer-related mortality in both men and women in Taiwan; it has a standardized mortality rate of 2.4%–4.0% (Health Promotion Administration, Ministry of Health and Welfare, 2023). Although Ocular Adnexal Lymphoma (OAL) ac-counts for only 1% of all non-Hodgkin’s lymphoma cases, it is one of the most commonly occurring malignant tumors of the ocular adnexa, representing approximately 55% of all orbital malignancies. Patients with OAL who receive radiotherapy, chemotherapy, or immunotherapy often have a 5-year survival rate between 50% and 94%, with the majority retaining favorable physiological functioning [1]. Although these clinical outcomes are favorable, individuals with OAL often experience periorbital pain, cancer- related anxiety, and visible disfigurement caused by tumor induced proptosis. These challenges may adversely affect patients’ quality of life and satisfaction with medical care [1-3]. Therefore, in addition to managing physical pain and psychological distress, clinical nurses should focus on facilitating positive adaptation to changes in physical appearance.

The current study describes the case of a patient given a diagnosis of lymphoma presenting with right-eye proptosis. He was initially hospitalized for diagnostic evaluation, underwent partial tumor resection, and subsequently received chemotherapy. During the course of hospitalization, he experienced persistent orbital pain and facial disfigurement, both of which were difficult for the patient to accept. In addition, he was the primary financial provider in his family, and consequently, he expressed feeling profound anxiety regarding the potential for a poor prognosis or death. These clinical observations motivated the author to document the case and the individualized and continual physical and mental care strategies implemented to comprehensively address the patient’s needs. This care experience may provide a reference for clinical nurses managing patients with similar conditions in future practice

OAL primarily involves the conjunctiva, lacrimal gland, orbital fat, lacrimal sac, and eyelids. Because it does not have prominent symptoms or lead to visible changes in the early stages of the disease, OAL is often difficult to differentiate from other orbital diseases. As it advances, patients may present with proptosis, palpable masses, periorbital swelling, ptosis, restricted ocular motility, globe displacement, and diplopia [1]. Achieving an ac-curate diagnosis of OAL requires the use of both imaging modalities and histopathological analyses, and treatment strategies for the disease commonly include radiotherapy, chemotherapy, or immunotherapy to achieve tumor reduction, with surgical resection considered on the basis of the patient’s clinical condition and response to initial therapy [1,4].

OAL may cause pain due to tumor compression in the orbital region. For patients who undergo surgery as part of treatment, postoperative wound pain may compound this discomfort, leading to such patients experiencing greater pain. Therefore, effective pain control is critical to improving the quality of life of such patients [1-2]. To achieve effective pain control, nurses should administer analgesics as prescribed, encourage patients to describe their pain experiences, and conduct thorough assessment to determine pain location, characteristics, severity, duration, and precipitating factors as well as to quantify pain using the Numerical Rating Scale (NRS, 0-10). Patients should also be provided with nutrition education, with an emphasis on consuming a high- protein diet and adequate vitamin C, which can support wound healing. Non-pharmacological strategies are as crucial as pharmacological strategies are in pain management, and nurses should implement strategies such as guided deep breathing and adjustment of positioning to minimize traction-induced pain [5]. In addition, research indicates that complementary therapies, such as music therapy and acupressure, can be effective in alleviating cancer-related and postoperative pain [6].

OAL often leads to proptosis, resulting in visible changes to facial appearance. These changes can trigger psychological responses such as depression, diminished self-esteem, and social withdrawal, ultimately undermining a patient’s sense of identity and self-worth. Facilitating positive coping in patients can help alleviate negative emotions and foster stronger emotional connections with others [1,7]. Nurses play a critical role in this process because they can help patients articulate their perceptions of and emotional responses to changes in their appearance through active listening, being present, engaging in empathetic communication, and initiating guided conversations. Developing an individualized care plan is also essential in addressing the psychosocial needs of patients with OAL. Such care plans may include sharing examples of successful adaptation, teaching strategies for concealing visible changes such as using clothing, accessories, or subtle makeup to cover up changes prior to tumor reduction, and encouraging family and friends to provide consistent emotional support throughout the care process. The Body Image Visual Analogue Scale (BIVAS) may be employed to evaluate a patient’s satisfaction with their body image following appearance changes; on the scale, 0 mm indicates extreme

dissatisfaction, and 100 mm indicates complete satisfaction [2]. Research also indicates that expressive writing interventions, such as those involving reflections on aspects of one’s body that one is grateful for or statements emphasizing perceived control, are effective in promoting acceptance of physical changes [7].

Patients who have been diagnosed with cancer commonly experience anxiety stemming from uncertainty regarding prognosis and the potential for mortality [3]. In addition, studies indicate that approximately 60% of patients’ experience varying degrees of anxiety prior to surgery. When effectively managed, anxiety can be reduced, which can lead to improved treatment adherence, accelerated wound healing, and reduced length of hospital stay [8]. In evaluating anxiety severity, nurses generally use assessment tools such as the Beck Anxiety Inventory (BAI), which categorizes anxiety levels as follows: 0 to 7, nor-mal; 8 to 15, mild; 16 to 25, moderate; and 26 to 63, severe. Furthermore, establishing a trusting nurse-patient relationship is essential; it can be achieved through being present, empathetic communication, and active listening. Providing patients with clear information about the progression of their disease, treatment plans, and follow- up care and inviting patients to participate in decision-making can enhance their sense of control. Moreover, receiving emotional support from family members, friends, and religious re-sources can enhance psychological well-being. Furthermore, complementary therapies such as music therapy, acupressure, and aromatherapy have been demonstrated to effectively reduce anxiety [3], [8-9].

Nursing Assessment

The patient in this case study is named Mr. Chang. He is a 41-year-old man, a high school graduate, and believes in Taoism. He is a fruit farmer and is married. He lives in a multigenerational household with his wife (aged 38 years), son (aged 10 years), father (aged 78 years), and mother (aged 77 years). The family is close and supportive. During Mr. Chang’s hospitalization, his wife was the primary caregiver.

Medical History and Current Hospitalization

Mr. Chang has no family history of cancer, no prior medical or surgical conditions, and no known allergies to food or medications. In early October 2023, he noticed mild proptosis of the right eye. By mid-October, the condition had progressed, with this ac-companied by a sensation of orbital fullness and pain. On October 26, he sought medical attention at the reporting hospital.

Computed tomography identified a 1 × 1.2 cm² mass in the right orbit, a 1 × 0.8 cm² mass in the right cervical region, and several subcentimeter lesions in the right axilla. Following clinical evaluation, surgical removal of the right cervical and axillary tumors was recommended. Chemotherapy was planned as the initial treatment for the orbital tumor, with ophthalmologic surgery to be considered thereafter. The patient was admitted on October 28. On October 29, he underwent surgical excision of the right cervical and axillary tumors with concurrent pathological sampling. A subclavian Port-A catheter was placed for subsequent chemotherapy administration. A whole-body positron emission tomography scan performed on November 1 identified multiple lymphatic lesions less than 0.3 cm in the right orbit, bilateral cervical regions, clavicular areas, and bilateral axillae. Pathological analyses confirmed a diagnosis of stage III malignant lymphoma. The patient was discharged on November 4 and subsequently continued outpatient follow-up and chemotherapy as scheduled.

Nursing Process

The patient received nursing care from October 28 to November 4, 2023. Data regarding this case were collected through observations, patient interviews, medical record re-views, physical assessment, and direct care. The information was organized using Gordon’s Eleven Functional Health Patterns framework, as detailed in the following:

Health perception and health management patterns

The patient reported no history of smoking, alcohol consumption, or betel nut chew-ing. He considered himself to be in good health, maintained a regular lifestyle, and routinely took multivitamins to support his well-being. When he experienced minor illnesses such as a cold, he typically self-medicated with over-the-counter drugs and sought hospital care only if his symptoms did not improve. Following his diagnosis of OAL, he initially struggled to accept that he had the condition, particularly because of his young age and role as the family’s primary financial provider. Nevertheless, he exhibited a proactive attitude; he cooperated with surgical treatment and sought information regarding chemo-therapy and ongoing care. He demonstrated adequate health perception and self-management; no problems related to this specific domain were noted.

Nutritional-metabolic patterns

The patient is 174.5 cm tall and weighs 71 kg, with a body mass index of 23.3 kg/m², which is within the normal range. Over the 3 months following the initiation of treatment, his weight remained stable, changing by less than 1%. He reported having a good appetite, no food aversions, and no specific dietary preferences. His typical meals consisted of 1 bowl of rice with vegetables and meat, and his daily fluid intake was approximately 1800 to 2000 mL. Laboratory data collected on October 28 revealed a hemoglobin level of 12 g/dL, sodium level of 137 meq/L, potassium level of 4.5 meq/L, albumin level of 4.0 g/dL, and white blood cell count of 8450/μL all of which are within normal reference ranges. On October 29, the patient underwent surgical excision of tumors in the right cervical and axillary regions, with incisions approximately 3 cm in length made at each site. A subclavian Port-A catheter was also inserted for subsequent chemotherapy administration. Throughout the postoperative period, sterile dressing changes were routinely performed. The patient maintained a good appetite and consistently finished his meals. Other than the wounds from surgery, his skin remained intact and elastic. His hair was black and glossy. The oral mucosa was healthy and intact, and his chewing and swallowing functions were normal. No nutritional or metabolic problems were identified.

Excretion Patterns

During hospitalization, the patient exhibited regular excretion patterns. Bowel movements occurred every 1 to 2 days and consisted of soft, medium-volume, yellow-brown formed stools. His daily urinary frequency ranged from 6 to 8 times, with a total urine output of approximately 1500 to 1800 mL. The urine appeared pale yellow, clear, and free of sediment. No deviations from his usual bowel or urinary habits were noted. Abdominal assessment revealed slight distension. Auscultation detected 7 to 10 bowel sounds per minute. Percussion produced mild tympany, and palpation confirmed a soft, nontender abdomen without palpable masses. No edema was observed in the extremities. Laboratory results obtained on October 28 revealed a blood urea nitrogen level of 6.1 mg/dL and a creatinine level of 0.62 mg/dL; both were within normal reference ranges. No excretion-related health problems were noted.

Activity and exercise patterns

Prior to hospitalization, the patient was fully independent in all activities of daily living. He regularly visited his orchard as part of his occupational routine and engaged in recreational physical activities such as family outings and hiking on weekends or during agricultural downtime. A chest X-ray conducted on October 28 revealed no notable abnormalities. During hospitalization, the patient scored 100 on the Activities of Daily Living scale, which indicated full functional independence. Muscle strength was graded 5/5 in all 4 limbs. The patient’s vital signs remained stable throughout his hospitalization: his body temperature ranged from 36.4°C to 37.1°C, his pulse from 67 to 85 beats per minute, his respiratory rate from 16 to 20 breaths per minute, and his blood pressure from 121 to 133/62 to 76 mmHg. His respirations were smooth, with oxygen saturation maintained at 98% to 100%. The patient exhibited good peripheral circulation; his extremities and lips were pink. Respiratory auscultation revealed clear lung sounds without adventitious noises such as crackles or wheezes. Although the orbital tumor resulted in right-eye proptosis due to local compression, his visual acuity remained mostly unaffected. His gait was stable and coordinated, and no mobility problems were identified.

Sleep and rest patterns

The patient did not require regular use of sleep aids. His usual routine involved going to bed before 10:00 p.m. and waking at 6:00 a.m. to inspect the orchard; this provided him with approximately 8 hours of uninterrupted sleep per night. He did not take daytime naps and reported good overall sleep quality. However, on October 28, he experienced difficulty in falling asleep due to right orbital discomfort and preoperative anxiety. After consulting with the physician, he was given an analgesic and Xanax (0.5 mg), which enabled him to sleep through the night. Following surgery on October 29, the prescribed analgesics and anxiolytics were continued. Throughout his hospitalization, the patient remained energetic during the day, with no signs of fatigue, excessive yawning, or dark circles under his eyes. He consistently reported achieving 8 hours of restful sleep each night. No sleep or rest problems were identified.

Cognitive-perceptual patterns

The patient had normal eyesight and was alert and fully oriented to person, place, and time. His cognitive functions, including his judgment, orientation, memory, and thought processing, were intact. His sensory perception, including his responses to temperature and pain, remained within normal limits. He was also able to accurately verbalize discomfort. On October 28, he reported, “My right eye has become more swollen and painful over the past few days. Sometimes the pain radiates to the right side of my head. Pressing on the eye worsens the pain. It typically takes about 30 to 40 minutes after I take analgesics for the discomfort to subside.” Physical assessment on the same day (October 28) revealed proptosis and swelling of the right eye caused by tumor compression. The patient exhibited signs of discomfort, including a furrowed brow, cold sweats, and frequent head rubbing. He rated his pain as 7 out of 10 on the NRS. On October 29, following surgery, the patient stated, “Now I feel pain on the right side of my neck, in my armpit, and in the area where the catheter was inserted. Moving causes discomfort in the areas where the wounds are. My right eye is also starting to hurt again. Can I have more pain medication?” Subsequent assessment revealed approximately 3-cm surgical wounds in both the right cervical and axillary regions, and a subclavian Port-A catheter was placed. The patient continued to furrow his brow, frequently pressed on his right eye with his left hand, and avoided movement because of wound discomfort. Assessment indicated the presence of acute pain.

Self-perception and self-concept pattern

The patient considered himself to be a mild-tempered, optimistic individual with a strong sense of responsibility toward his family. Prior to his cancer diagnosis, he maintained positive relationships with his family and friends and was generally perceived to be cheerful and outgoing. On October 28, he expressed, “I want to decline all visitors except my wife. With how I look now, I don’t want others to see me.” He further inquired, “Can I keep wearing a hat? When I leave the ward to get water or go to the convenience store, I feel like my eye is bulging. If it frightens even me myself—imagine how others must feel.” During the same day, the patient was observed wearing a hat at all times in an attempt to conceal the protrusion of his right eye. He declined visits from anyone other than his wife and consistently drew the bedside curtain while in the room. Even when receiving nursing care, he kept his head lowered to avoid exposing his right eye. On October 29, he asked the nurse: “Do you think my right eye looks ugly? Will I scare people if I go out? I really think I look worse every time I see myself.” He was seen repeatedly examining his right eye in the mirror and questioning the nurses about his appearance. He demonstrated signs of denial and dissatisfaction regarding his physical changes. Assessment conducted using the BIVAS yielded a score of 25 mm, indicating significant dissatisfaction with his body image. This assessment revealed a disturbance in body image.

Role and relationship pattern

The patient’s primary role is that of an adult male; his secondary roles include being a husband, son, father, and fruit farmer. His tertiary role is a patient with cancer. Within his household, the patient is both the main decision-maker and the main financial provider. The family has a stable financial status, with no outstanding loans, and the patient’s hospitalization expenses have been covered by insurance. On October 30, his wife shared, “Although we sometimes argue over minor daily matters, our family is close, and we genuinely care for one another. Earlier, my in-laws had a video call with us and our son to express their concern.” Throughout his hospitalization, the patient had positive interactions with his wife, who remained with him and provided consistent emotional support. During episodes of anxiety or pain, she exhibited empathy and offered comfort and encouragement. The patient also consistently had cooperative and respectful interactions with the health-care team. No health concerns were identified in this domain.

Sexuality and reproductive patterns

The patient married at age 30 and currently has 1 child. He reported maintaining a regular sexual relationship with his wife, typically engaging in sexual activity 1 to 2 times per week, using condoms for contraception. Over the past 2 weeks, the frequency had de-creased to approximately once per week because of orbital pain; however, this change had not affected the couple’s emotional intimacy. During the patient’s hospitalization, physical assessment revealed no abnormalities in the genital area and no unusual discharge. No health concerns were identified in this domain.

Coping and stress tolerance patterns

The patient stated that under normal circumstances, he copes with stress by spending time in the orchard, discussing problems with his wife, or socializing with his friends over tea. However, his cancer diagnosis posed a considerable emotional and physical burden. On October 28, he reported, “Since I’ve learned that I have cancer, I’ve been feeling low. I often feel agitated and constantly fear that it might be untreatable that I might die.” He also shared, “The surgery is scheduled for tomorrow. Although I know it’s just a minor excision and biopsy, it’s my first surgery, so I feel nervous.” On the day of surgery, he appeared visibly anxious when discussing his diagnosis furrowing his brow, lowering his head, and frequently sighing. He exhibited signs of emotional distress related to both the cancer diagnosis and the upcoming procedure. Assessment conducted using the BAI revealed a score of 28, indicating moderate anxiety. After the physician explained the pathological findings and positron emission tomography scan results to the patient on November 1, the patient was shocked, stating, “What? A malignant tumor? And there are more tumors in other areas? What am I supposed to do? I still have to support my family!” He further inquired, “Will chemotherapy completely cure this? Is there a high chance of recurrence?” He appeared visibly tense clenching his fists, rubbing his hands, and repeatedly expressing concerns over the prognosis and effectiveness of chemotherapy. On the basis of these responses and behavior, the patient was determined to be experiencing clinically significant anxiety.

Values and belief patterns

The patient believes in Taoism and routinely engages in ancestral worship during the Chinese New Year and other major holidays. Prior to his admission, he and his wife visited a temple to pray for smooth surgery and treatment outcomes. On November 2, he ex-pressed, “I used to think that earning more money to provide for my family was my top priority, but now I realize that health is the foundation of everything without it, I can’t work or support my family. I’m truly relying on you. I will fully cooperate with the treatment.” No health concerns were noted in this domain.

Problem Identification

According to the aforementioned assessment, the patient demonstrated the following health concerns: acute pain associated with tumor-induced compression of the right eye and postoperative surgical wounds; disrupted body image related to changes in physical appearance caused by proptosis of the right eye due to tumor compression; and anxiety resulting from the initial cancer diagnosis, upcoming surgical procedures, and uncertain-ty regarding prognosis and treatment outcomes.

Table 1: Acute pain associated with tumor-induced compression of the right eye and postoperative surgical wounds (October 28 to November 4).

Table 2: Acute pain associated with tumor-induced compression of the right eye and postoperative surgical wounds (October 28 to November 4).

Table 3: Anxiety resulting from the initial cancer diagnosis, upcoming surgical procedures, and uncertainty regarding prognosis and treatment outcomes (October 28 to November 4).

Discussion and Conclusions

This study presents a nursing care experience involving a patient with a new diagnosis of lymphoma, which had led to his right-eye proptosis. During hospitalization, the patient underwent a series of diagnostic evaluations, including a pathological biopsy, and was scheduled to receive outpatient chemotherapy following discharge. Throughout the course of care, 3 primary health concerns were identified: acute pain, body image disturbance, and anxiety. Pharmacological pain management was administered as pre-scribed by the attending physician. In parallel, non- pharmacological strategies including music therapy, comfortable positioning, and acupressure were introduced, and they effectively reduced the patient’s perceived pain. To address the patient’s psychological, dis-tress related to his altered appearance, the care team encouraged him to openly express his emotions and discussed practical methods for concealing the visible effects of proptosis during his social interactions. Expressive writing was implemented as a structured intervention, with it used to help the patient gradually accept changes in his appearance. A trusting nurse-patient relationship was fostered through active listening, being present, and empathetic communication. An interdisciplinary team provided the patient with disease-specific education and reinforced the use of non-pharmacological anxiety-reduction techniques, including music therapy, acupressure, and aromatherapy. These interventions aligned with findings from the reviewed literature. Before discharge, follow-up outpatient appointments were arranged, and the patient was referred to an oncology case manager for continued support. A detailed handover of the patient’s medical and psychosocial needs was conducted. At that time, the patient’s self-perceived body image as measured using the BIVAS was 60 mm. As part of the postdischarge care plan, the patient, his spouse, and the case manager agreed to continue the expressive writing intervention, with support in the form of regular telephone follow-ups by the case manager and outpatient visits. The patient

reported in an outpatient follow-up on November 20 that he had consistently engaged in the daily expressive writing practice. His BIVAS score had risen to 75 mm, indicating a notable improvement in his self-image and a greater lev-el of acceptance toward the changes in his physical appearance.

Although the study hospital actively promotes evidence-based practice, it lacks a comprehensive framework for integrating various evidence-based interventions into clinical workflows. For example, in the current case, expressive writing was incorporated into care, and although the nursing staff were aware of its evidence-based rationale, their individual interpretations of and methods of implementing the intervention varied considerably. This inconsistency led to uneven patient education and implementation of the intervention. To address this problem in future cases, a dedicated evidence integration team can be established to develop standardized guidelines and protocols for each evidence-based intervention. Furthermore, offering online training courses would enhance nursing staff’s knowledge of interventions and ensure consistent application across the care team. Such initiatives would facilitate individualized nursing care tailored to patient needs while ensuring consistency in the implementation of care practices.

Declaration of Competing Interest

The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.

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