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on how to render the best possible care to a patient suffering from Lung CA. To be able to define Lung CA as well as on how it is acquired, risk factors, signs and symptoms. To be able to know the pathophysiology of Lung CA. To be able to know the other problems that the client is suffering right now. To gain more information about patients condition.
To apply skills learned in the classroom to actual handling and caring for a patient who suffered/ is suffering from Lung CA. To determine the possible nursing intervention that will be of great help in the patients prognosis. To be able to give the appropriate health teaching and better understanding of the disease to the patient, family and significant others.
In the year 2000, the Philippines had a total number of 6,395 reported deaths that was caused by cancer of the lungs, as documented by the DOH (Philippine Health Statistics 2000, DOH) Slow-growing lung adenocarcinoma, in actuality, is the most common kind of lung cancer both in smokers and non-smokers, and in people under age 45. Adenocarcinoma makes up for about 30 percent of primary lung tumors in male smokers and 40 percent in female smokers. For nonsmokers, these percentages approach 60 percent in males and 80 percent in females. This is also more common in Asian populations.
Cancer of the lung, like all cancers, results from an abnormality in the body's basic unit of life, the cell. Normally, the body maintains a system of checks and balances on cell growth so that cells divide to produce new cells only when needed. There are two main types of lung cancer, non-small cell lung cancer and small cell lung cancer. First is the Non-small Cell Lung Cancer. NSCLC accounts for about 80%of lung cancers.
There are different types of NSCLC, including Squamous cell carcinoma(also called epidermoid carcinoma). This is the most common type of NSCLC. It forms in the lining of the bronchial tubes and is the most common type of lung cancer in men. Adenocarcinoma This cancer is found in the glands of the lungs that produce mucus. This is the most common type of lung cancer in women and also among people who have not smoked.
The second type of lung cancer is the Small cell Lung Cancer. SCLC accounts for about 20% of all lung cancers. Although the cells are small, they multiply quickly and form large tumors that can spread throughout the body. Smoking is almost always the cause of SCLC
STATISTICAL DATA
Here in the Philippines, lung cancer kills 80% of those diagnosed (8,518 or 14.2% mortality among 10,643 or 17.4% incidence) of all those diagnosed with the disease compared to 35% mortality among breast cancer. Every year, there are about 20,000 smoking related deaths in the country.
Source: http:/www.tribuneonline..org/metro/20101212met5.html
Although smoking frequently causes this type of cancer, secondary risk factors include Age Family history Exposure to secondhand smoke Exposure to mineral and metal dust, asbestos, or radon.
Symptoms develop slowly as well. They include: Coughing shortness of breath Wheezing chest pain and bloody sputum Sometimes, this illness may appear at first to be pneumonia or a collapsed lung. Sometimes the spread of this cancer produces large amounts of fluid building up around the lung.
Nationality: Filipino
Date of Admission: February 21, 2011 Time: 08:45 am Admitting Diagnosis: Lung Cancer, Stage II Case Number: 25112 Admitting Physician: Dr. Giovanni Lagoc, MD
A. PRESENT HEALTH HISTORY 3 yrs. prior to admission, the client quitted smoking and there he experienced withdrawal syndrome. 8 months prior to admission around June 2010, he felt difficulty in sleeping, night sweat, chest pain, difficulty in
2 months prior to admission around December 2010, he complained of difficulty swallowing and sleeping
accompanied by severe cough by then they consulted a physician and after several test he was then diagnosed to have a Lung cancer, stage 2. 1 month prior to admission around January 2011, he complained of difficulty urinating and defecating,
hoarseness, numbness in the left upper extremities. 1 day prior to admission at February 20, 2011, he was
B. PAST HEALTH HISTORY He hadnt experience any disease when he was a child even when he turned into teenage life. But when he was at his
and her mother has asthma. His wife said that their family
is in good health, and that this is the first time that someone had a cancer in their family.
D. DEVELOPMENTAL HISTORY EXPERIENCE Erik Eriksons Psychosocial Stages of Development: Integrity versus Despair VERBALIZATION INTERPRETATION INTEGRITY; As individuals approach the end of life, they tend to take stock of the years that have gone before. Our client feels a sense of satisfaction with his accomplishments in life.
Tanggap ko na kung anu mang ipagkaloob ng maykapal, kunin man nya ako, handa na ako., as verbalized by the patient.
Grade 6 ako unang ORAL STAGE; Freud believed that all nanigarilyo, isang stick human beings pass kada isang araw through a series of psychosexual stages; hanggang sa maging each stage dominated isang kaha na isang by the development of sensitivity in a araw., as verbalized particular erogenous or pleasure giving by the patient. spot in the body. Furthermore, each stage poses for individual a unique conflict that they must resolve before they go to the next higher stage. If individuals are unsuccessful in resolving the conflict, the resulting frustration becomes chronic and remains a central feature of their psychological makeup.
E. SOCIO ECONOMIC A person who was diagnosed of having a lung cancer must undergo certain procedures that cost much to maintain living and prevent further complications. Given the privilege from raising his children, patient XXX was being supported financially by her daughter working
hospitalization and other needs such as medications, foods, and etc. are being provided by his other relatives. Since he and his wife dont have work, they are seeking for help in sustaining their daily needs from their children and other relatives.
F. PYCHOLOGICAL STATUS
BEFORE THE ILLNESS Patient XXX was fond of smoking and considers cigarette as a part of his daily life. He thought that he couldnt live without a
cigarette in his life and feels that his strength comes from his vice.
Despite the prohibition of his daughter who is a nurse and his relatives, Patient XXX cant stop himself from smoking.
successfully cease his smoking habit to relieve feeling of illness. His first
time trying not to smoke made him realize that it is hard to turn his back in his daily habit and he stated, Tanggap ko na kung ano mang ipagkaloob sa akin ng Panginoon as verbalized by the patient.
G. SOCIO CULTURAL
XXX.
I. NUTRITIONAL
BEFORE HOSPITALIZATION DURING HOSPITALIZATION
Breakfast 2-3 cups of rice 1 med. size fried fish 1 cup coffee 1-2 glasses of water Lunch 2-3 cups of rice 1 servings of vegetable 1 med. size pork 2-3 glasses of water Snack 4-5 pcs. Bread 1 glass of water Dinner 2-3 cups rice 1 serving of vegetable 2-3 glasses of water
He ate meals in a moderate When he was diagnosed, the manner- the usual meal for a doctor ordered a soft diet for sedentary man him to take.
His usual oral fluid intake was At the hospital, Patient XXs about 6-7 glasses of water per fluid and electrolytes was
through and
supported by oral fluid intake. Before the illness, patient XXX Previously, patient XXX weighs
J. ELIMINATION
J. ELIMINATION
BEFORE HOSPITALIZATION The patient defecates for at least 1-2 times a day. January 2011 the patient defecates twice or thrice a week. DURING HOSPITALIZATION Sometimes the patient defecates once a day and sometimes none. February 2011, the patient has difficulty in voiding, he defecates twice or thrice a week. The patient urinates approximately 4-6 times a day with no other problems in voiding. During his hospitalization, the patient has difficulty in urinating. He uses adult diaper, he consumes 2 diapers per day. DURING HOSPITALIZATION
K. EXERCISE
BEFORE HOSPITALIZATION
The patient was able to ambulate around their house and going to the store without any assistance in his side.
The patient experienced fatigue and weakness due to decrease in oxygen level in the body.
L. HYGIENE
BEFORE
HOSPITALIZATION He takes a bath 1-2
DURING
HOSPITALIZATION His relative provides
He can trim nails by his His relative is the one self. who trim his nails.
L. HYGIENE
BEFORE HOSPITALIZATION
DURING HOSPITALIZATION
He usually sleeps around ten oclock in the evening and awake at five oclock in the morning or earlier.
M. SLEEP
He had a difficulty in sleeping due to the attacks of his condition including coughing.
AREA
METHODS
FINDINGS
INTERPRETATION
Integumenta ry Skin
Inspection
-normal, older persons skin becomes pale due to decreased melanin production and decreased dermal vascularity.
* Janet Weber, Jane H. Kelley; Health Assessment in Nursing 3rd Edition 2007Chapter 11 p. 166
Palpation
-older persons skin loses its turgor because of a decrease in elasticity and collagen fibers. Also, their skin may feel dryer because sebum production decrease with age. * Janet Weber, Jane H. Kelley; Health Assessment in Nursing 3rd Edition 2007-
Hair
- black to gray color - well distributed in the scalp and in the overall skin
-normal, gray or white hair is also result as a person ages because decrease in or a lack of melanin production. * Rod R. Seeley, Trent D. Stephens, Philip Tate; Essentials of Anatomy and Physiology 6th Edition, International Edition 2007- Chapter 5 Integumentary System p.112 - may indicate hypoxia
Inspection
Nails Inspection
Head
- results from inflammatory changes in the bones of the fingers from prolonged oxygen deficiency. * The Respiratory System Chapter 12 p. 283 symmetrical skull - normal and is appropriate in size symmetrical facial features no lumps or bumps on the scalp
- sclera is white - conjunctiva clear & pinkish in color - no blurring of vision - pupils equally round, reactive to light and accommodation (PERRLA) Inspection - eyes did not converge
- normal
- indicates a weakness in one or more extraocular muscles or dysfunction of the cranial nerve that innervates the particular muscle.
* Janet Weber, Jane H. Kelley; Health Assessment in Nursing 3rd Edition 2007Chapter 13 p. 225
- symmetrical ears and equal in - normal size - no build up of cerumen/ear wax - can hear whispered words at a distance of 1 ft. in both ears
- no pain reported upon palpation - normal and no presence of swelling Palpation both ear auricles non tender
- patient can breathe with one nostril and the other is occluded
- no presence of discharge - no presence of bumps and tenderness
Palpation
- normal
- normal
- because of weakened respiratory muscles and decreased ciliary movement. - yellowish teeth with some tooth decays, - persons who smoke and missing tooth may have yellow or brownish teeth
* Janet Weber, Jane H. Kelley; Health Assessment in Nursing 3rd Edition 2007 - Chapter 15 p. 281
- normal
- normal
Trachea
Inspection
- normal
Auscultation
- coarse crackle heard in the tracheal site during early inspiration to early expiration butterfly in shape, in midline - normal position, non palpable lobes, not enlarged, and rises as patient swallows - symmetrical chest shape & - normal size - no barrel chest - use of accessory muscles, - the use of accessory (scalene and muscles facilitates sternocleidomastoid) muscles inspiration of O2 while breathing
* Janet Weber, Jane H. Kelley; Health Assessment in Nursing 3rd Edition 2007 - Chapter 16 p. 310
Inspection - there are retractions of the - indicates an increased intercostals spaces inspiratory effort. This may be the result of an obstruction of the respiratory tract.
* Janet Weber, Jane H. Kelley; Health Assessment in Nursing 3rd Edition 2007 - Chapter 16 p. 318
- upon deep breathing anterior thoracic expansion: approx. 5 cm. ; posterior thoracic expansion: approx. 6 cm. - symmetrical expansion Palpation increased fremitus in the upper region of the lungs
- because of loss of the accessory musculature in older persons thoracic expansion may be decreased although it should still be symmetrical
* Janet Weber, Jane H. Kelley; Health Assessment in Nursing 3rd Edition 2007 Chapter 16 p. 313
* Janet Weber, Jane H. Kelley; Health Assessment in Nursing 3rd Edition 2007 Chapter 16 p. 312
- dullness is present when fluid or solid tissue replaces air in the lung or occupies the pleural space as in tumor.
Breath sounds
- coarse crackles heard in - inhaled air comes into contact the 2nd L and R intercostals with secretions in the large space during early bronchi inspiration to early * Janet Weber, Jane H. Kelley; Health expiration Assessment in Nursing 3rd Edition 2007 Chapter 16 p. 317
Auscultation
- wheezing heard in the 6th L - as air passes through and R intercostals space constricted passages (caused during expiration by swelling, secretions, or tumor) a high-pitched, musical sound is produced
* Janet Weber, Jane H. Kelley; Health Assessment in Nursing 3rd Edition 2007 Chapter 16 p. 317
- S1 corresponds with each carotid pulsation. S2 immediately follows after S1 - no extra heart sounds and murmurs
- no bruits upon auscultation of the carotid arteries - jugular vein not distended Peripheral Vascular system (peripheral pulses, veins, and perfusion) - uniform in color, presence of -Normal pallor there is slow capillary - capillary refill of nail beds is 3 nailbed refill with secs. respiratory or cardiovascular diseases that cause hypoxia * Janet Weber, Jane H. Kelley; Health Assessment in Nursing 3rd Edition - Chapter 11 p. 175 - peripheral pulses (radial, brachial, and -Normal femoral) are equal in pulse rate and rhythm - pink coloration returns to palms in 4 secs. if ulnar artery is patent and 3secs. if radial artery is patent.
Inspection
- bulging veins
* Janet Weber, Jane H. Kelley; Health Assessment in Nursing 3rd Edition - Chapter 30 p. 856
Palpation Nipples size, shape, position, color, discharge & lesions Axillary, subclavicul ar & supraclavic ular lymph nodes
Inspection
- nipples at same level - normal on chest, and of same dark brown color, no presence of lesions
Palpation
- enlarged, hard, nonmobile left supraclavicular lymph node, approximately 2 cm. in diameter; no pain reported
- the left supraclavicular lymph node drains the thorax, abdomen via thoracic duct. Common causes of enlargement include lymphoma, thoracic cancer, bacterial or fungal infection.
* Metastases in Supraclavicular Lymph Nodes in Lung Cancer: Assessment with Palpation, US, and CT. Radiology 2004;232: 75-80.
sunken observed
abdomen
Inspection
of - normal the
Palpation
abdominal respiratory movement is seen no palpable mass, no pain reported no tenderness and is soft lower edge of liver is palpable and is firm & even; other organs non palpable - normal bowel sounds: 5 -Normal times/min, heard in all four quadrants
Vascular sounds
- no bruits over abdominal aorta - normal & femoral arteries - no friction rubs over area of liver & spleen tympany is heard over abdomen dullness over the liver and spleen - decreased muscle mass, tone, several changes and strength occur in aging skeletal muscle that reduce - rate of muscle strength is 4 muscle mass. There is active motion against some loss of muscle fiber & resistance fast-twitch muscle fibers as aging occurs. The number of motor neurons also decrease
* Rod R. Seeley, Trent D. Stephens, Philip Tate; Essentials of Anatomy and Physiology 6th Edition, International Edition 2007Chapter 7 Muscular System p.194
Inspection
Inspection
Bones
Inspection
- normal
an exaggerated thoracic curve (kyphosis) is common with aging
Joints
- non tender joints - normal - bilaterally equal decreased ROM - the ligament & except R arm tendon surrounding a joint shorten & become less flexible with age, resulting in a decrease in ROM of the joints. Inspection
* Rod R. Seeley, Trent D. Stephens, Philip Tate; Essentials of Anatomy and Physiology 6th Edition, International Edition 2007Chapter 6 Skeletal System p.151
-normal
good grooming, dresses appropriately to weather speech is of appropriate age and flows easily maintains eye contact, can smile & frown appropriately awake, alert, and oriented to time, place, person, and responds to stimuli Glascow coma Scale: score of 15
-normal
Cranial nerves CN I decreased sense of smell elderly people experience only a slight loss in the ability to detect odors.
CN II
-normal
Inspection
CN III, IV, & VI - eyes did not converge - indicates a weakness in one or more extraocular muscles or dysfunction of the cranial nerve that innervates the particular muscle.
* Janet Weber, Jane H. Kelley; Health Assessment in Nursing 3rd Edition 2007- Chapter 13 p. 225
CN V
CN VII
temporal and masseter muscles contract bilaterally correctly identified sharp and dull stimuli of an object can smile, frown, show yeeth, puff out his cheeks, raise eyebrows. These are all symmetrical in movement. - can hear whispered words at a distance of 1 ft. in both ears
- normal
- normal
CN IX & X
uvula and soft palate rises bilaterally and symmetrical upon saying ah gag reflex is present
- normal
CN XI
there is symmetric but weak contraction of the trapezius muscles upon shrugging of shoulders against resistance
-most of the loss of strength in an elderly is due to the loss of muscle fibers and the loss of fast-twitch muscle fibers. * Rod R. Seeley, Trent D. Stephens, Philip Tate; Essentials of Anatomy and Physiology 6th Edition, International Edition 2007Chapter 7 Muscular System p.194
CN XII
- normal
Reflexes
Biceps reflex
both elbows flexed and contraction of biceps muscle is felt both elbows extended, triceps muscles contracts knee extends, quadriceps contracts
normal
Triceps reflex
Achilles reflex
Achilles reflex
Motor functions
Inspection
-
normal
information on the position, tension, and length of tendons and muscles also decreases, resulting in additional reduction in the senses of movement, posture, and position, as well as reduced control and coordination of movement
* Rod R. Seeley, Trent D. Stephens, Philip Tate; Essentials of Anatomy and Physiology 6th Edition, International Edition 2007Chapter 8 Nervous System p.237
- the surface area of the neuromuscular junction decreases and, as a result, action potentials in neurons stimulate action potential production in muscle cells more slowly and fewer action potentials are produced in the muscle fibers.
* Rod R. Seeley, Trent D. Stephens, Philip Tate; Essentials of Anatomy and Physiology 6th Edition, International Edition 2007Chapter 8 Muscular System p.194
there is a general decline in the number of motor neurons. Muscle fibers innervated by the lost motor neurons are lost.
* Rod R. Seeley, Trent D. Stephens, Philip Tate; Essentials of Anatomy and Physiology 6th Edition, International Edition 2007Chapter 8 Nervous System p.237
Sensory functions
Inspection
decreased light touch sensation correctly identifies direction of movement of fingers & toes with eyes is closed
as a result of decreases in the number of skin receptors, elderly people are less conscious of something touching or pressing on the skin.
* Rod R. Seeley, Trent D. Stephens, Philip Tate; Essentials of Anatomy and Physiology 6th Edition, International Edition 2007Chapter 8 Nervous System p.237
Genitals/Inguinal:
Inspection
* Janet Weber, Jane H. Kelley; Health Assessment in Nursing 3rd Edition - Chapter 30 p. 860-861
Palpation
Rectum/Anus: Inspection
- anus is darker than normal findings in an elderly person the surrounding * Janet Weber, Jane H. Kelley; Health Assessment in skin rd
Nursing 3 Edition - Chapter 30 p. 861
Others:
Senses Inspection - numbness in his neck, left shoulder and arm, - there is compression of the left subclavian artery & brachial plexus
Oncologists talk about stages of lung cancer based on something called the TNM system. In this system, T refers to the size of the tumor, N refers to the involvement of any lymph nodes and where they are located, and M indicates if there are any metastases, that is spread of the tumor to other regions of the body.
Using the TNM system, stage 2 lung cancer is described as: 2A T1N1M0 Meaning the tumor is less than 3 cm (1 inches) in size, and it has spread to nearby lymph nodes. 2B T2N1M0 The tumor is greater than 3 cm is size and has spread to local lymph nodes, or T3N0M0 The tumor is any size and has not spread to lymph nodes, but is located in the airway or has spread to local areas such as the chest wall or diaphragm.
ANATOMY
The lungs are a pair of cone-shaped breathing organs in the chest. The lungs bring oxygen into the body as you breathe in. They release carbon dioxide, a waste product of the bodys cells, as
Each lung has sections called lobes. The left lung has two lobes, while the right lung is slightly larger and has three lobes. Two tubes called bronchi, lead from the trachea (windpipe) to the right and left lungs. These bronchi are sometimes also involved in lung cancer disease process.
Tiny air sacs called alveoli and small tubes called bronchioles make up the inside of the lungs. A thin membrane called the pleura covers the outside of each lung and lines the inside wall of the chest cavity. This creates a sac called the pleural cavity. The pleural cavity normally contains a small amount of fluid that helps the lungs move smoothly in the chest when you breathe.
Mechanism of Breathing
Passage of Cigarette Smoke to lower respiratory system Nicotine Tars Carbon Monoxide Ability to Phagocytize inhaled Foreign Particles
Goblet Cells
Exposure / inhalation of infected aerosol through droplet Inhaled nuclei lodge in alveoli Binding of bacterial cell wall to macrophage
Spread of bacilli via lymphatic system to upper lobes of the lungs Tubercle bacilli replicates slowly due to sensitivity to heat
Formation of granuloma Increased tumor size Drainage of necrotic material into the tracheobronchial tree
Scar formation Migrate via lymph nodes or blood circulation Full blown immunity of bacilli
Active infection of Bacilli -hemoptysis -productive cough -chest pain and tightness -night sweating (May 2010)
FNAB Dec. 23, 2010 Non small cells lung cancer Positive for Adenocarcinoma
May 22, 2010 X-ray shows Kochs infection at right upper lobe
January 2011 -hoarseness -dysphagia -Non- productive cough -anorexia -weight loss
May 2010 Started anti-tubercular drugs for six months (May-Nov. 2010)
Recurring of symptoms after 6 months of treatment February13, 2011 -hoarseness -dysphagia -Non- productive cough -numbness of the Left neck, shoulder & arm -dyspnea -wheezes on 6th intercostal space -crackles on trachea & 2nd intercostals space -palpable lymph node on left neck
Dec. 13, 2010 Pulmonary mass lingular segment, with mediastinal and Left Hilar lymphadenopathy, biopsy is suggested PTB of undetermined activity, Right upper lobe
Dec. 23, 2010 Unchanged right upper lobe PTB and left hilar mass
RADIOLOGIC FINDINGS
IMPRESSION:
Minimal Kochs infection, Right upper lobe. Interstitial pneumonitis Right hemothorax. Consolidation pneumonia Lingular zone. Please correlated clinically.
November 2, 2010
RADIOLOGIC FINDINGS
IMPRESSION:
Follow up study since June 12, 2010 shows progression of the confluent opacities in the Left peri hilar area and Left lower lobe. Note of slight interval clearing of the Right upper lobe infiltrated. No other interval changes seen.
December 12, 2010 RADIOLOGIC FINDINGS IMPRESSION: Pulmonary mass lingular segment, with mediastinal and Left Hilar lymphadenopathy, biopsy is suggested PTB of undetermined activity, Right upper lobe Atherosclerotic aorta
RADIOLOGIC FINDINGS
IMPRESSION: Resolving Pneumonia, Left Hilum. Unchanged right upper lobe PTB and left Hilar mass. Mild cardiomegaly. Atherosclerotic thoracic aorta. Degenerative osseous changes.
December 23, 2010
FNAB
IMPRESSION:
Positive for malignant cells. Non small cell compatible with adenocarcinoma.
DATE
2/ 21/11
TIME
8:45 am
DOCTORS ORDER
admit
INTERPRETATION
To monitor the condition of the patient and for implementation of proper treatment.
secure consent
It protects the clients right to selfdetermination. To inform the client on what treatment or procedure he/she might be involved.
to avoid aspiration
DATE
TIME
DOCTORS ORDER
IVF D5 NM 1L x 12 hours
INTERPRETATION
for replacement of fluid and electrolyte loss
Decreases shortness of breath. Nasal Cannula delivers a relatively low concentration of oxygen which is 24% to 45% at flow rates of 2 to 6 liters per minute. it promotes total expansion of the lung
DATE
TIME
DOCTORS ORDER
Nebulizaton with salbutamol + ipratropium q 8 1 amp.
INTERPRETATION
salbutamol relieves nasal congestion and reversible bronchospasm by relaxing the smooth muscles of the bronchioles. ipratropium relieve any reversible airways blockage associated with problems such as repeated infections affecting the airways. For further studies of the disease and for more improved medical management.
refer
Meds:
Dexamethasone 250 g IV q8
Dexamethasone reduces the swelling, itching, and redness that can occur in these types of conditions. This medication is a mild corticosteroid.
TREATMENT
Surgery: Surgical removal of the tumor is generally performed for limited-stage (stage I or sometimes stage II) NSCLC and is the treatment of choice for cancer that has not spread beyond the lung. About 10%-35% of lung cancers can be removed surgically, but removal does not always result in a cure, since the tumors may already have spread and can recur at a later time.
The surgical procedure chosen depends upon the size and location of the tumor. Surgeons must open the chest wall and may perform a wedge resection of the lung (removal of a portion of one lobe), a lobectomy (removal of one lobe), or a pneumonectomy (removal of an entire lung). Sometimes lymph nodes in the region of the lungs also are removed (lymphadenectomy). Surgery for lung cancer is a major surgical procedure that requires general anesthesia, hospitalization, and follow-up care for weeks to months. Following the surgical procedure, patients may experience difficulty breathing, shortness of breath, pain, and weakness. The risks of surgery include complications due to bleeding, infection, and complications of general anesthesia.
Radiation: Radiation therapy may be employed as a treatment for both NSCLC and SCLC. Radiation therapy uses high-energy X-rays or other types of radiation to kill dividing cancer cells. Radiation therapy may be given as curative therapy, palliative therapy (using lower doses of radiation than with curative therapy), or as adjuvant therapy in combination with surgery or chemotherapy. The radiation is either delivered externally, by using a machine that directs radiation toward the cancer, or internally through placement of radioactive substances in sealed containers within the area of the body where the tumor is localized. Brachytherapy is a term used to describe the use of a small pellet of radioactive material placed directly into the cancer or into the airway next to the cancer. This is usually done through a bronchoscope.
Radiation therapy does not carry the risks of major surgery, but it can have unpleasant side effects, including fatigue and lack of energy. A reduced white blood cell count (rendering a person more susceptible to infection) and low blood platelet levels (making blood clotting more difficult and resulting in excessive bleeding) also can occur with radiation therapy. If the digestive organs are in the field exposed to radiation, patients may experience nausea, vomiting, or diarrhea. Radiation therapy can irritate the skin in the area that is treated, but this irritation generally improves with time after treatment has ended.
Chemotherapy: Both NSCLC and SCLC may be treated with chemotherapy. Chemotherapy refers to the administration of drugs that stop the growth of cancer cells by killing them or preventing them from dividing. Chemotherapy may be given alone, as an adjuvant to surgical therapy, or in combination with radiotherapy. While a number of chemotherapeutic drugs have been developed, the class of drugs known as the platinumbased drugs have been the most effective in treatment of lung cancers. Chemotherapy is the treatment of choice for most SCLC, since these tumors are generally widespread in the body when they are diagnosed. Only half of people who have SCLC survive for four months without chemotherapy. With chemotherapy, their survival time is increased up to four- to fivefold. Chemotherapy alone is not particularly effective in treating NSCLC, but when NSCLC has metastasized, it can prolong survival in many cases.
Chemotherapy may be given as pills, as an intravenous infusion, or as a combination of the two. Chemotherapy treatments usually are given in an outpatient setting. A combination of drugs is given in a series of treatments, called cycles, over a period of weeks to months, with breaks in between cycles. Unfortunately, the drugs used in chemotherapy also kill normally dividing cells in the body, resulting in unpleasant side effects. Damage to blood cells can result in increased susceptibility to infections and difficulties with blood clotting (bleeding or bruising easily).
Other side effects include fatigue, weight loss, hair loss, nausea, vomiting, diarrhea, and mouth sores. The side effects of chemotherapy vary according to the dosage and combination of drugs used and may also vary from individual to individual. Medications have been developed that can treat or prevent many of the side effects of chemotherapy. The side effects generally disappear during the recovery phase of the treatment or after its completion.
Assessment
Diagnosis
Planning
Interventions
Rationale
Evaluation
S> Naninikip and dibdib ko as verbalized by the patient O> with productive cough With mucous secretions: scant in amount Clear , thick whitish sputum >use sternocleidomas toid muscles and scaline muscles while breathing >with clubbing of fingers in both hands. > RR= 12bpm
Impaired gas exchange related to altered oxygen supply as evidenced by clubbing of fingers
GOAL: Adequate gas exchange DESIRED OUTCOMES After the nursing interventions, the patient will be able to : a. Demonstr ate improved ventilation and adequate oxygenatio n. b. Participate in treatment regimen with in level of ability or situation
INDEPENDENT >Note respiratory rate, depth and ease of respiration. >Observe for the use of accessory muscle, pursed lip breathing, changes in skin or mucous membrane color.
>Respiration may be increase as a result of pain or as an initial compensatory mechanism to accommodate for loss of lung tissue. Increased work of breathing and cyanosis may indicate increasing oxygen consumption and energy expenditures and reduced respiratory reserve >Airway obstruction impedes ventilation, impairing gas exchange. >maximize lung expansion and drainage of secretions.
After series of nursing intervention the patient was able to demonstrate improve ventilation and adequate oxygenation.
>Maintain patent airway >Reposition frequently, placing patient in sitting positions and supine to side positions.
Assessment
Diagnosis
Planning
Interventions >encourage or assist with deep breathing exercises and pursed lift breathing as appropriate DEPENDEN T >Administer supplemental oxygen via nasal cannula, partial rebreathing mask, or high humidity face mask as indicated. Oxygen saturation: 12 L/min
Rationale >promote maximal ventilation and oxygenation and reduces or prevent atelectasis
Evaluation
Assessmen t
S>Nahihirapan akong huminga as verbalized by the patient O > with productive cough >with mucous secretions o Scant in amount and o Clear, thick, whitish sputum
Diagnosi s
Ineffective airway clearance related to constriction of the airway as evidenced by decreased respiratory rate:12bpm and deep shallow breathing.
Planning
GOAL: Effective airway clearance Desired Outcome: After nursing intervention patient will be able to: a. Demonstrat e patent airway b. Expectorate secretions c. Clear breath sounds d. Decrease use of accessory muscles for breathing e. Demonstrat e behavior to improve or maintain clear airways
Interventions
Independent: >Auscultate chest for character of breath sounds and presence of secretions >Observe amount and character of sputum secretions. Investigate changes as indicated >encourage oral intake if not contraindicated and within cardiac tolerance. Dependent: >Administer bronchodilators, expectorants and/ or analgesics as indicated
Rationale
Evaluation
After series of nursing interventions, patient will demonstrate patent airway, will have expectorated secretions and decrease use of accessory muscles while breathing.
>noisy respiration, ronchi, and wheezes are indicative of retained secretions and/or airway obstruction >presence of thick and tenacious bloody or purulent sputum suggest development of secondary problems >adequate hydration aids in keeping secretions loose or enhance expectorations
>with crackles breath sounds heard on the second intercoastal spaces >with wheezing on the sixth intercoastal space heard upon expiration
>relieves bronchospasms to improve airflow. Expectorants increases mucous production and liquefy and reduce viscosity of secretions, facilitating removal. Alleviation or chest discomfort promotes cooperation and breathing exercises and enhances effectiveness of respiratory therapies.
Assessment
S> Hindi na ako makagawa ng datirati kong ginagawa dito sa bahay as verbalized by the patient. O>decreased physical activity > easy fatigability >body malaise >RR; 12bpm >decrease depth of breathing >poor muscle tone
Diagnosis
Activity intolerance related to imbalance between oxygen Supply and demand as evidence by decreased physical activity & easy fatigability
Planning
Goal: Enhance activity tolerance Desired Outcome: After nursing interventions, patient will be able to: a. Participate in techniques to enhance activity tolerance b. Eliminate and reduce factors that contribute activity tolerance c. Demonstrat ea decrease in physiologica l signs of intolerance
Intervention s
Independent: >evaluate clients response to activities. >Note reports of dyspnea, increased weakness or fatigue, and changes in vital signs during and after activities. >Encourage use of stress management and diversional activities as appropriate. >Assist and encourage to assume comfortable position for rest and sleep.
Rationale
>Establishes clients capabilities or needs and facilitates choice of intervention >Symptoms may be result of/or contribute to intolerance of activity
Evaluation
After nursing intervention patient will be able to: Participate in techniques to enhance activity tolerance Eliminate and reduce factors that contribute activity intolerance Demonstrate a decrease in psychological signs or intolerance.
>Patient may be comfortable with head of bed elevated, sleeping in chair or leaning forward on overbed table with pillows support.
Assessment
Diagnosis
Planning
Intervention s
>Encourage adequate fluid intake
Rationale
>Prevents dehydration (which increases fatigue)
Evaluation
>weakness may make ADLs difficult to complete or place patient at risks for injury during activities.
>Presence of hypoxemia reduces oxygen available for cellular uptake and contributes to fatigue.
DRUG NAME
ACTION
INDICATION
CONTRAINDICATION
ADVERSE REACTION
>Stimulates Beta2 receptors Feb.21 2011 of bronchioles Generic Name: by increasing the levels of Nebulizaton cAMP which with relaxes smooth SALBUTAMOL muscles to + ipratropium q produce bronchodilation. 8 1 amp. Date Ordered:
> Relief and prevention of bronchospasm in patients with reversible obstructive airway disease or COPD >Inhalation and treatment of acute attack of bronchospasm
Brand Name:
Activent Dosage and Frequency: 1Neb. 1amp every 8 hours. Classification: Symphatomim etics
>Hypersensitivit y to a salbutamol, also to atrophine and its derivatives. >Cardiac arrhythmia associated w/ tachycardia caused by digitalis intoxication.
>Fine skeletal muscle tremor, leg cramps, palpitations, tachycardia, hypertension, headache, nausea, vomiting, dizziness, hyperactivity, insomnia,
DRUG NAME
ACTION
INDICATION
CONTRAINDICATION
ADVERSE REACTION
NURSING RESPONSIBILITIES
>Assess patients pain (location, type, character) before therapy and regularly thereafter to monitor drug effectiveness. >Assess for hypersensitivity reactions:pruritus, rash and urticaria. >Monitor for possible drug induced adverse reactions: CNS: stimulation, dizziness, vertigo, headache, somnolence, anxiety, confusion, coordination disturbance, malaise, euphoria, nervousness, sleep disorder, seizures.
Date Ordered: Feb.21 2011 Generic Name: Tramadol Brand Name: Dolotral Dosage and Frequency: Classification: Analgesics, Muscle Relaxants and Uricosurics Corticosteriods .
>Centrally acting analgesic not chemically related to opioids but binds to muopioid receptors and inhibits reuptake of norepinephrine and serotonin.
>Hypersensitivit y >Acute intoxication with alcohol, hypnotics, centrally acting analgesics, opioids, or psychotropic agents.
>Vasodilation: Dizziness/vertig o, headache, somnolence, stimulation, anxiety, confusion, coordination disturbance, sleep disorders, seizures. >Pruritus, sweating, rash. >Visual disturbances, dry mouth. >Nausea, diarrhea, constipation, vomiting, dyspepsia, abdominal pain, anorexia, flatulence.
DRUG NAME
ACTION
INDICATION
CONTRAINDIC ATION
ADVERSE REACTION
NURSING RESPONSIBILITIES
Dexamethason e 250 g IV q8
Brand Name: Decilone Dosage and Frequency: Classification:
Hormones and
related drugs.
>Synthetic glucocorticoid w/ marked antiinflammatory effect because of its ability to inhibit prostaglandin synthesis, inhibit migration of macrophages, leukocytes and fibroblasts at sites of inflammation, phagocytosis and lysosomal enzyme release. It can also cause the reversal of increased capillary permeability.
>Respiratory diseases
>Thromboembol ism or fat embolism; thromboplebitis; necrotizing angiitis; cardiac arrhythmias or ECG changes. >vertigo > headache >Impared wound healing >visual acuity >thoat irritation
> Obtain pt. history of underlying condition before therapy. >Assess for possible drug induced adverse reaction. >Monitor renal status and function. >Assess mental status: Affect, mood, behavioral changes. >Assess pts and familys knowledge on drug therapy.
DRUG NAME
ACTION
INDICATION
CONTRAINDIC ATION Hyper sensitivity to soya lecithin or related food products. Atropine or any anticholinergic derivates.
NURSING RESPONSIBILITIES >Assess patients condition before and after drug therapy. Monitor peak expiratory flow. >Monitor for evidence of allergic reactions, paradoxic bronchopspasm . >Assess pt and familys knowledge on drug therapy. >Inform pt. that drug is not effective for treatment of acute bronchopspasm >Teach pt. the proper way of drug administration.
Date Ordered: Feb. 21, 2011 Generic Name: Nebulizaton with salbutamol + IPRATROPIUM q 8 1 amp. Brand Name: Atrovent
Classification:
Anticholinergic s
Chemically related to atropine, it antagonizes the effect of acetylcholine. It causes a local and site specific bronchodilatatio n by preventing the increase in intracellular cyclic guanosine monophosphate which produced by the interaction of acetylcholine w/ the muscarinic receptors of the bronchial smooth muscles.
Acute exacerbations of chronic obstructive pulmonary disease (COPD). Used in conjunction w/ betaadrenergic stimulant for acute asthmatic attacks.
DRUG NAME
ACTION
INDICATION
CONTRAINDIC ATION Patients with hx of sensitivity reactions to drug or its components Patients with marked myelosuppressi on induced by previous treatment with other antitumor drugs or therapy
Generic Name: doxorubin HCl Brand Name: Adriamycin Injection: 2mg/ml 20mg/m2 IV once weekly Classification: Antineoplastic s
DRUG NAME
ACTION
INDICATION
CONTRAINDIC ATION Patients hypersensitive to drug and those with infectious diseases Patients with severe anemia or depressed neutrophil and PLT count Patient who underwent radiation therapy or chemotherapy
ADVERSE REACTION nausea, vomiting, snorexia, diarrhea, leukopenia, mild anemia thrombocytopen ia, agranulocytosis
NURSING RESPONSIBILITIES >Dilute using up to 100 ml saline for injection >Turn pt side to side every 5 to 10 mins. To distribute drug To prevent bleeding, avoid all IM injections when PLT count is less than 50, 000/mm3 Monitor pt closely for bone marrow suppression Give BT for cumulative anemia
Cross-links strands of mechlorethami cellular DNA and interferes ne Hcl with RNA Brand Name: transcription,cau Mustargen sing an Injection: 10mg imbalance of growth that vials leads to cell o.4 mg/kg death. intracavitarily Generic Name: Classification: Antineoplastic s
DRUG NAME
ACTION
INDICATION
CONTRAINDIC ATION Patients hypersensitive to drug and those with infectious diseases Patients with severe anemia or depressed neutrophil and PLT count Patient who are pregnant or lactating
ADVERSE REACTION nausea, vomiting, snorexia, diarrhea, leukopenia, mild anemia thrombocytopen ia, kidney toxicity
NURSING RESPONSIBILITIES >Monitor CBC and hepatic function tests Monitor electrolytes (such as calcium, magnesium, potassium, and sodium levels Maintain a good fluid intake WOF fever or any other signs of infection Provide mouth care
Cisplatin is classified as an cisplatin alkylating agent. Alkylatin Brand Name: g agents are Platinol most active and Injection: kill cells during 60 to 100 the resting phase of the mg/m2 cell. These intravenously on drugs are cell day one every cycle nonGeneric Name: 21 days (in combination with other antineoplastic drugs) Classification: Antineoplastic s specific.
Used to treat testicular, ovarian, bladder, head and neck, esophageal, small and nonsmall cell lung, breast, cervical, stomach and prostate cancers. Also to treat Hodgkin's and nonHodgkin's lymphomas, neuroblastoma, sarcomas, multiple myeloma, melanoma, and mesothelioma
ACTION
>Assess respiratory rate and depth
RATIONALE
>useful in evaluating the degree of respiratory distress and /or chronicity of the disease process .
>cough can be persistent but ineffective, especially if client is elderly, acutely ill, or debilitated.
ACTION
>Encourage adequate rest periods between activities
RATIONALE
>to limit fatigue
>Give frequent oral care, remove expectorated secretions promptly, provide specific container for disposal of secretions and tissue
>noxious tastes, smell and sight are prime deterrents to appetite and can produce nausea and vomiting with increase respiratory difficulty
MEDICATION Inform client to take medications on time, or as directed for the full course of therapy, even if feeling better. Inform the client about the possible side effects of the medication.
Encourage the client to report or inform the physician if any of side effects occur. Inform and explain to the client in simple terms that other drugs, such as over the counter drugs that he or she is taking, will probably have other effects with the medication given. Moreover, emphasize the right timing or taking or the right time intervals of these drugs to maximize its effects and avoid further complications. Provide information for better understanding regarding therapeutic regimen
EXERCISE Encourage ambulation. Patient will be given deep breathing exercises to promote lung expansion. Use an incentive spirometer to promote deep breathing
EXERCISE Encourage ambulation. Patient will be given deep breathing exercises to promote lung expansion. Use an incentive spirometer to promote deep breathing
DIET Encourage eight to 10 glasses of water and non-caffeinated beverages per day, plenty of fruits and vegetables as well as lower fat foods. Encourage to eat high fiber foods such as fruits and vegetables
TREATMENT Instruct the client to continue drug therapy as ordered. Inform the client as well as the family the dangers of non compliance to treatment regimen. Discuss to the client the complication of the condition. Inform client to do exercises and stretches. Instruct the patient to report to the physician promptly about any changes on health condition. Encourage patient to strictly comply with the doctors orders, especially in taking prescribed medications Encourage the patient to have followed up visitations to the physician after discharge
OUTPATIENT Remind client on the arrangements to be made with the physician for follow-up check ups Follow-up check up regularly in order to monitor and properly manage patients illness. Continue medication as ordered. Instruct to have a follow-up check-up or refer to the physician if the patient is uncomfortable Instruct the client and significant others to report for any unusualities
This case study has provided us with important information about the patients lung cancer disease condition and its nursing care interventions prior to the treatments and medical procedures done with the patient.
Challenges make us more responsible. Always remember that, life without struggles is a life without success. Dont give up. Learn to rest, but NEVER QUIT future RNs!