case presentation lung ca final

8/13/2019 Case Presentation Lung CA Final

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The general objective of this case study is to

broaden our knowledge about the disease and

to develop skills 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 thatthe client is suffering right now.

To gain more information about patient’s

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

patient’s prognosis. To be able to give the appropriate health

teaching and better understanding of the

disease to the patient, family and significant

others.



DESCRIPTION OF HEALTH CONDITION

In the year 2000, the Philippines had a total

number of 6,395 reported deaths that was causedby 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 insmokers 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 non-

smokers, 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 LungCancer. 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 mostcommon type of lung cancer in women and

also among people who have not smoked.



The second type of lung cancer is theSmall 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 cancerproduces large amounts of fluid building up

around the lung.



Name: Mr. XXX

Address: Brgy. Dila Bay, Laguna

Age: 66 years old

Date of Birth: May 28, 1945

Place of birth: Calauan, Laguna

Religion: Roman CatholicNationality: 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

breathing and productive cough.

7 months prior to admission around July 2010, he was

advised to have chest X-ray and after that he had been

treated with RIPES for 6 months then after 6 months he

complained of feeling bad and that the treatment givenafforded no relief.



2 months prior to admission around December 2010, he

complained of difficulty swallowing and sleeping

accompanied by severe cough by then they consulted aphysician 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

admitted due to productive cough, difficulty of breathing,chest pain, weakness, hoarseness, pain in the right neck

and numbness in the left upper extremities.



B. PAST HEALTH HISTORY

He hadn’t experience any disease when he was a child

even when he turned into teenage life. But when he was at his

adulthood stage of life he was exposed to measles by then he

didn’t have any serious complications until he reaches the age

of 65 where he experienced having severe cough that soonbecame his present condition, lung cancer. One factor was that

he started smoking when he was in grade 6, 1 stick per day and

continued till he used to smoke 1 pack per day. When he

reached the age of 63 he quitted smoking.



C. FAMILY HEALTH HISTORY

According to the patient, none of the members of

their family has cancer. His father has diabetes mellitus

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.



EXPERIENCE VERBALIZATION INTERPRETATION

Erik Erikson’s

Psychosocial Stages

of Development:

Integrity versus

Despair

“Tanggap ko na

kung anu mang

ipagkaloob ng

maykapal, kunin

man nya ako,handa na ako.”, as

verbalized by the

patient.

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.

D. DEVELOPMENTAL HISTORY



Sigmund Freud’s

Psychosexual Stages of

Development:

“Grade 6 ako unang

nanigarilyo, isang stick

kada isang araw

hanggang sa maging

isang kaha na isang

araw.”, as verbalized

by the patient.

ORAL STAGE;

Freud believed that all

human beings pass

through a series of

psychosexual stages;

each stage dominatedby the development of

sensitivity in a

particular erogenous

or pleasure giving

spot in the body.

Furthermore, each

stage poses forindividual a unique

conflict that they must

resolve before they go

to the next higher

stage. If individuals

are unsuccessful inresolving the conflict,

the resulting

frustration becomes

chronic and remains a

central feature of their

psychological make-

up.



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

abroad as a nurse. He receives ₱10,000.00 monthly for the

examinations and tests he must undergo. His

hospitalization and other needs such as medications,

foods, and etc. are being provided by his other relatives.

Since he and his wife don’t 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 couldn’t 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 can’t stop himself from smoking.

WHEN DIAGNOSED / DURING ILLNESS

When patient XXX felt difficulty sleeping, swallowing

and having productive cough, his family consulted a doctor for him. When

advised by the doctor to quit smoking, he thought that he could

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

One of patient XXX’s child is a Registered Nurse,

this served as a main factor that influenced his health belief – which is

to seek medical treatment. They first consulted a doctor when he felt ill

and preferred Medical Management for his health. However, they also

believed in “faith healers”, as some of Filipino’s tradition.

H. SPIRITUAL

As Christians, patient XXX and his family was able

to deal with God in their daily lives. When he was diagnosed with Lung

Cancer, the family entrusted patient XXX’s life on God’s hand andprepared themselves in accepting whatever will happen to patient

XXX.



I. NUTRITIONAL

BEFORE HOSPITALIZATION DURING HOSPITALIZATION

Breakfast

2-3 cups of rice1 med. size fried fish

1 cup coffee

1-2 glasses of water

Breakfast

2-3 tbsp. soup½ glass of water

Lunch

2-3 cups of rice1 ½ servings of vegetable

1 med. size pork


Lunch

3-4 tbsp. soup½ glass of water

Snack

4-5 pcs. Bread

1 glass of water

Dinner

2-3 cups rice

1 serving of vegetable


Dinner

2-3 tbsp. soup

½ glass of water



He ate meals in a moderate

manner- the usual meal for a

sedentary man

When he was diagnosed, the

doctor ordered a soft diet for

him to take.

His usual oral fluid intake was

about 6-7 glasses of water perday, with exception to coffee

and beverages.

At the hospital, Patient XX’s

fluid and electrolytes wasmaintained through

intravenous fluids and

supported by oral fluid intake.

Before the illness, patient XXX

weighs about 65 kilograms.

Previously, patient XXX weighs

about 40 kilograms, due to his

unusual eating habits and

having difficulty swallowing.

J ELIMINATION



J. ELIMINATION

BEFORE HOSPITALIZATIONDURING HOSPITALIZATION

The patient defecates for at least 1-2

times a day.

January 2011 the patient defecates

twice or thrice a week.

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.

J. ELIMINATION

K. EXERCISE


The patient was able to ambulate

around their house and going to

the store without any assistance in

his side.

The patient was able ambulate with

assistance in his side.

The patient experienced fatigue and

weakness due to decrease in oxygen

level in the body.



L. HYGIENE

BEFORE

HOSPITALIZATION

DURING

HOSPITALIZATION

He takes a bath 1-2

times a day with Luke

warm water.

His relative provides

sponge bath to him.

He brushes his teeth

every after meal.

He brushes his teeth

irregularly.

He can change and

wear clothes or dress if

ever he wants.

His wife changes his

cloth or any available

relatives.

He can trim nails by his

self.

His relative is the one

who trim his nails.



L. HYGIENE

M. SLEEP


He usually sleeps around

ten o’clock in the evening

and awake at five o’clock

in the morning or earlier.

He had a difficulty in

sleeping due to the attacks

of his condition including

coughing.

He has a productive cough

with clear white sticky

mucous secretions.

The patient sleeps five

hours or less due to

ambiance of hospital.



AREA METHODS FINDINGS INTERPRETATION



AREA METHODS FINDINGS INTERPRETATION

Integumenta

ry

Skin

Inspection

- brown

- even in

overall skin

color

- presence ofpaleness of

the skin

-normal, older person’s

skin becomes pale due

to decreased melanin

production and

decreased dermalvascularity.

* Janet Weber, Jane H.

Kelley; Health

Assessment in Nurs ing

3 rd Edi tion © 2007-

Chap ter 11 p. 166

Palpation

- poor skin

turgor

- dry, warm

-older person’s skin

loses its turgor because

of a decrease in

elasticity and collagen

fibers. Also, their skin

may feel dryer becausesebum production

decrease with age.


Kelley; Health

Assessment in Nurs ing3 rd Edi tion © 2007-

Hair - black to gray color -normal, gray or white hair



Inspection

g y

- well distributed in

the scalp and in the

overall skin

, g y

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

Nails Inspection - pale nail beds - may indicate hypoxia

- clubbing of fingers - results from inflammatory

changes in the bones of

the fingers from prolonged

oxygen deficiency.

* The Respiratory System

Chap ter 12 p. 283 Head

Skull &

Face

Inspection

- symmetrical skull

and is

appropriate in

size

- symmetrical

facial features

- no lumps or

bumps on thescalp

- normal

Eyes & - sclera is white - normal



Eyes &

Vision

Inspection

- sclera is white

- conjunctiva clear & pinkish in

color

- no blurring of vision

- pupils equally round, reactive to

light and accommodation

(PERRLA)

- normal

- 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; HealthAssessment in Nurs ing 3 rd Editio n © 2007-

Chapter 13 p. 225

Ears &

Hearing

Inspection

- symmetrical ears and equal in

size

- no build up of cerumen/ear wax

- can hear whispered words at a

distance of 1 ft. in both ears

- normal

Palpation

- no pain reported upon palpation

and no presence of swelling

both ear auricles non tender

- normal

Nose & - nose is symmetrical in shape and same - normal



Nose &

Sinuses

Inspection

- nose is symmetrical in shape and same

in color with face

- patient can breathe with one nostril and

the other is occluded

- no presence of discharge

- normal

Palpation

- no presence of bumps and tenderness

no pain reported - normal

- non tender sinuses

Mouth

&

Orophar

ynx

Inspection

- no presence of lesions

- pink, moist oral mucosa

- no dentures

- normal

- cough reflex is weaker - because of weakened

respiratory muscles

and decreased ciliary

movement.

- yellowish teeth with some tooth decays,

and missing tooth

- persons who smoke

may have yellow or

brownish teeth

* Janet Weber, Jane H. Kelley;Heal th Assessment in Nurs ing 3 rd

Edition © 2007 - Chapter 15 p. 281

Neck

Neck

muscle

s

Inspection

- symmetrical but weak in strength

- symmetrical movement of neck

muscles

- normal

Lymph

nodes

of theneck

Palpation

lymph nodes are non palpable - normal



Palpation

- upon deep breathing

anterior thoracic expansion:

approx. 5 cm. ; posterior

thoracic expansion: approx.

6 cm.

- symmetrical expansion

- 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

- increased fremitus in

the upper region of the

lungs

- usually the result of

consolidation or bronchial

obstruction* Janet Weber, Jane H. Kelley; Health

Assessment in Nurs ing 3 rd Edit ion © 2007 -

Chapter 16 p . 312

Percussion

- dullness present - dullness is present when fluidor solid tissue replaces air in

the lung or occupies the pleural

space as in tumor.

Breath sounds

Auscultation

- coarse crackles heard in

the 2nd L and R intercostals

space during early

inspiration to early

expiration

- inhaled air comes into contact

with secretions in the large

bronchi



Chapter 16 p. 317

- wheezing heard in the 6th L

and R intercostals space

during expiration

- as air passes through

constricted passages (caused

by swelling, secretions, or

tumor) a high-pitched, musical

sound is produced



Chapter 16 p. 317

Cardiovascular & - S1 corresponds with each carotid -



PeripheralVascular System

Heart(Sounds)

Auscultation

1 p

pulsation. S2 immediately followsafter S1

- no extra heart sounds andmurmurs

Central vessels(carotid arteries

& jugular vein)

Palpation

- equal in pulse rate, rhythm ofcarotid arteries, and amplitude of2+

- normal

- no bruits upon auscultation ofthe carotid arteries

- jugular vein not distended

Peripheral

Vascular

system

(peripheral

pulses, veins,

andperfusion)

Inspection

- uniform in color, presence ofpallor

-Normal

- capillary refill of nail beds is 3

secs.

there is slow capillary

nailbed refill with

respiratory or

cardiovascular diseases

that cause hypoxia


Kelley; Health

Assessment in Nursing

3rd Edition - Chapter 11

p. 175

- peripheral pulses (radial, brachial, and

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.

-Normal



- bulging veins - normal findings in an

elderly person


Assessment in Nurs ing 3 rd Edition - Chapter

30 p. 856

Breast & Axillae

Breast size,

symmetry &

contour/shape

Inspection

- breasts are relatively

equal

- normal

Palpation

- no presence ofhardness in any area

Nipples

size, shape,position,

color,

discharge &lesions

Inspection

- nipples at same level

on chest, and of samedark brown color, nopresence of lesions

- normal

Axillary,

subclavicul

ar &

supraclavicular lymphnodes Palpation

- enlarged, hard, non-

mobile left

supraclavicular lymph

node, approximately 2cm. in diameter; no painreported

- the left supraclavicular

lymph node drains the

thorax, abdomen via thoracic

duct. Common causes ofenlargement include

lymphoma, thoracic cancer,

bacterial or fungal infection.* Metastases in Supraclavicular Lymph

Nodes in Lung Cancer : Assessment wi th

Palpation, US, and CT. Radiology 2004;232:

75-80.



Abdomen:

Abdominal

contour,symmetry

Inspection

- sunken abdomen isobserved

- a scaphoid (sunken)

abdomen may be seenwith severe wieght loss


Assessment in Nurs ing 3 rd Edition ©

2007 - Chapter 20 p. 441

- symmetrical, no presence ofscars, lesions

- normal

- slight pulsation of

abdominal aorta in theepigastric region

- abdominal respiratorymovement is seen

- normal

Palpation

- no palpable mass, nopain reported

- no tenderness and issoft

- lower edge of liver is

palpable and is firm &

even; other organs non

palpable Bowel

sounds

Auscultation

- normal bowel sounds: 5

times/min, heard in all fourquadrants

-Normal

Vascular no bruits over abdominal aorta normal



Vascularsounds

Inspection

- no bruits over abdominal aorta& femoral arteries

- no friction rubs over area ofliver & spleen

- normal

- tympany is heard overabdomen

- dullness over the liver and

spleen

MusculoskeletalSystem:

Muscle

Inspection

- decreased muscle mass, tone,and strength

- rate of muscle strength is 4 –

active motion against someresistance

- several changes

occur in aging skeletal

muscle that reduce

muscle mass. There is

loss of muscle fiber &

fast-twitch muscle

fibers as aging occurs.

The number of motorneurons also decrease


D. Stephens, Phil ip Tate;

Essentials of Anatomy and

Phys io logy 6th Edi t ion,

International Edition © 2007-

Chapter 7 Muscular System p.194

Bones

Inspection

- no deformities & fractures - normal

- exaggerated thoracic curve - an exaggeratedthoracic curve

(kyphosis) is commonwith aging



Joints

Inspection

- non tender joints - normal

- bilaterally equal decreased ROMexcept R arm

- the ligament &

tendon surrounding a

joint shorten &

become less flexible

with age, resulting in a

decrease in ROM of

the joints.


D. Stephens, Phil ip Tate;

Essent ia ls of Anatomy and

Phys io logy 6th Edi t ion,


Chapter 6 Skeletal System p .151

- Non tender joints -normal

Neurologic:

Mentalstatus Inspection

- good grooming, dressesappropriately to weather

- speech is of appropriate ageand flows easily

- maintains eye contact, cansmile & frown appropriately

-normal

Level ofconsciousness Inspection

- awake, alert, and oriented totime, place, person, and

responds to stimuli –

Glascow coma Scale: scoreof 15



CN IX & X - uvula and soft palate rises bilaterally andsymmetrical upon saying “ah”

fl

- normal



- gag reflex is present

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,


Chapter 7 Muscular System

p.194

CN XII - tongue movement is symmetrical and

smooth and strength is bilateral

- normal

Reflexes

Deep tendon

reflex

Inspection

Biceps reflex - both elbows flexed and contraction of

biceps muscle is felt

- normal

Triceps reflex - both elbows extended, triceps muscles

contracts

Triceps reflex

Patellar reflex

(knee-jerk

reflex)

- knee extends, quadriceps contracts Patellar reflex (knee-

jerk reflex)

Achilles reflex - both foot has plantar flexion Achilles reflex



Sensoryf ti

- decreased

li h h

- as a result of decreases in the

b f ki ld l



functions

Inspection

light touchsensation

- correctly

identifies

direction ofmovement of

fingers & toes

with eyes isclosed

number of skin receptors, elderlypeople are less conscious of

something touching or pressingon the skin.


D. Stephens, Phil ip Tate; Essentials of Anatom y and

Physio logy 6th Editio n, Internation al Edition © 2007-

Chapter 8 Nervous System p.237

Genitals/Inguinal:

Inspection

- pubic hair isthin.

- normal findings in an elderlyperson

* Janet Weber, Jane H. Kelley; Health Assessm ent in

Nurs ing 3 rd Editio n - Chapter 30 p. 860-861

Palpation

- penis andtestes sizedecreased

- no swellingand no masses

Rectum/Anus:

Inspection

- anus is darker than

the surroundingskin

- normal findings in an elderly

person * Janet Weber, Jane H. Kelley; Health Assessm ent in

Nurs ing 3 rd Edition - Chapter 30 p. 861

Others:

Senses

Inspection

- numbness in his

neck, left shoulderand arm,

- there is compression of the leftsubclavian 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 ifthere 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 3cm (1 ½ inches) in size, and it has spread to

nearby lymph nodes.

2B – T2N1M0 – The tumor is greater than 3 cm issize 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 theairway or has spread to local areas such as the

chest wall or diaphragm.



ANATOMY



The lungs are a pair of cone-shaped breathingorgans in the chest. The lungs bring oxygen into

the body as you breathe in. They release carbon

dioxide, a waste product of the body’s cells, as

you breathe out.



Each lung has sections called lobes.

The left lung has two lobes, while the

right lung is slightly larger and hasthree lobes.

Two tubes called bronchi, lead from

the trachea (windpipe) to the rightand left lungs. These bronchi are

sometimes also involved in lung

cancer disease process.



Tiny air sacs called alveoli and small



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 chestcavity. This creates a sac called the

pleural cavity.

The pleural cavity normally contains asmall amount of fluid that helps

the lungs move smoothly in the

chest when you breathe.



Mechanism of Breathing



PREDISPOSING FACTORS-Gender

PRECIPITATING FACTORS-Smoking History: 53 pack-yrs. of



Age: 65 y/o

g y y

smoking

Passage of Cigarette Smoke

to lower respiratory system

Nicotine Tars Carbon Monoxide

Goblet

CellsMucocilliary Clearance

System Impairement

Ineffective Cough

Reflex

Impaired Alveolar

Macrophages

Ability to

Phagocytize

inhaled

Foreign

Particles

Chronic irritation and exposure

of epithelial tissue to smoking

↑ Vulnerability of epithelial tissue toirritants and carcinogens

Interruption of Normal cells

Activation of normal cancer cell

Primary growth of tumor in theepithelial tissue

- Desquamation of cells

-Hypersecretion of mucus

-Hyperplasia of the basal cells

-Metaplasia of normal

Respiratory epithelium

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



Failure of the immune system torecognize cancer cell as foreign

body

Patient stopped for smoking 2

years ago (2008)

Progression and proliferation of

cancer cellsProgression of tubercle bacilli

Increased tumor size Formation of granuloma

Obstruction of the

bronchus due to

tumor

Cancer cell

detached from

primary tumor

Tumor enlarges

through blood

vessels

Migrate via lymph

nodes or blood

circulation

Cancer cells

established at

secondary sites

FNAB Dec. 23, 2010

Non small cells lungcancer

Positive for

Adenocarcinoma

Drainage of necrotic material

into the tracheobronchial tree

Scar formation

Full blown immunity of bacilli

Active infection of Bacilli-hemoptysis

-productive cough

-chest pain and tightness

-night sweating

(May 2010)

May 22, 2010

X-ray shows Koch’s infection

at right upper lobe



January 2011

-hoarseness

-dysphagia-Non- productive cough

-anorexia

-weight loss

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

May 2010Started anti-tubercular drugs

for six months (May-Nov.

2010)

Recurring of symptoms after 6

months of treatment

Dec. 13, 2010

•Pulmonary masslingular segment, with

mediastinal and LeftHilar lymphadenopathy,

biopsy is suggested•PTB of undetermined

activity, Right upper lobe

Dec. 23, 2010Unchanged right upper lobe

PTB and left hilar mass



J 12 2010



Ju ne 12, 2010

RADIOLOGIC FINDINGS

IMPRESSION:

•Minimal Koch’s 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 23 2010



December 23, 2010

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

FNABIMPRESSION:

•Positive for malignant cells.

•Non small cell compatible with adenocarcinoma.



DATE TIME DOCTOR’S ORDER INTERPRETATION

2/ 21/11 8:45 am admit To monitor the

condition of the

patient and for

implementation of

proper treatment.

secure consent It protects the

client’s right to

self-

determination.

To inform the

client on what

treatment or

procedure he/she

might be involved.

TPR q shift &record

to know if there’sany alteration on

vital signs

DAT if not

dyspneic

to avoid

aspiration




IVF D5 NM 1L x 12

hours

for replacement of fluid and

electrolyte loss

O2 at 1-2 L/min via

nasal cannula

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.

moderate high back

rest

it promotes total expansion of the

lung




Nebulizaton with

salbutamol +

ipratropium q 8 1 amp.

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.

refer For further studies of the

disease and for more

improved medical

management.

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 treatmentof 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 alreadyhave 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 generalanesthesia, 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 includecomplications 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 amachine 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 todescribe 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 mayexperience 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

ith h th Ch th f t th



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 tosurgical therapy, or in combination with radiotherapy.

While a number of chemotherapeutic drugs have been

developed, the class of drugs known as the platinum-

based 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 usedin 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 orbruising 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 sideeffects 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 , thickwhitish sputum

>use

sternocleidomas

toid muscles

and scaline

muscles while

breathing

>with clubbingof 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

ateimproved

ventilation

and

adequate

oxygenatio

n.

b. Participate

intreatment

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.

>Maintain patent

airway

>Reposition

frequently,

placing patient in

sitting positions

and supine to

side positions.

>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 andenergy 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 todemonstrate

improve

ventilation

and

adequate

oxygenation.

Assessment Diagnosis Planning Interventions Rationale Evaluation



>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: 1-2 L/min

>promote

maximal

ventilation

and

oxygenation

and reduces

or prevent

atelectasis

>Maximizesavailable

oxygen,

especially

while

ventilation is

reduced

because of

pain.

Assessment

Diagnosis

Planning Interventions Rationale Evaluation



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

>with crackles

breath sounds

heard on the

second

intercoastal

spaces

>with wheezing

on the sixth

intercoastal

space heard

upon expiration

Ineffective

airway

clearance

related to

constriction

of the airway

as evidenced

by

decreased

respiratory

rate:12bpm

and deep

shallow

breathing.

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 improveor maintain

clear

airways

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

>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

>relieves

bronchospasms to

improve airflow.

Expectorants increases

mucous production andliquefy and reduce

viscosity of secretions,

facilitating removal.

Alleviation or chest

discomfort promotes

cooperation and

breathing exercises and

enhances effectiveness

of respiratory therapies.

After series of

nursing

interventions,

patient will

demonstrate

patent airway,

will have

expectorated

secretions and

decrease use

of accessory

muscles while

breathing.

Assessment Diagnosis Planning Intervention

s

Rationale Evaluation



s

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

Activity

intolerance

related to

imbalance

between oxygen

Supply anddemand as

evidence by

decreased physical

activity & easy

fatigability

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

e adecrease in

physiologica

l signs of

intolerance

Independent:

>evaluate client’s

response to

activities.

>Note reports of

dyspnea, increased

weakness or

fatigue, and

changes in vital

signs during and

after activities.

>Encourage use of

stressmanagement and

diversional

activities as

appropriate.

>Assist and

encourage to

assume

comfortableposition for rest

and sleep.

>Establishes

client’s capabilities

or needs and

facilitates choice

of intervention

>Symptoms may

be result of/or

contribute to

intolerance of

activity

>Reduces stress

and excess

stimulation,

promoting rest

>Patient may be

comfortable with

head of bed

elevated, sleepingin chair or leaning

forward on

overbed table with

pillows support.

After nursing

intervention

patient will be able

to:

Participate in

techniques toenhance activity

tolerance

Eliminate and

reduce factors that

contribute activity

intolerance

Demonstrate a

decrease in

psychological signs

or intolerance.



Assessment Diagnosis Planning Intervention

s

Rationale Evaluation

>Encourageadequate fluid

intake

>Assist with self

care needs when

indicated and

ambulation

Dependent:

>Provide

supplemental

oxygen asindicated at 1-

2L/min.

>Preventsdehydration

(which increases

fatigue)

>weakness may

make ADLs

difficult to

complete orplace patient at

risks for injury

during activities.

>Presence of

hypoxemia

reduces oxygen

available forcellular uptake

and contributes

to fatigue.



DRUG NAME ACTION INDICATION

CONTRAINDI-CATION

ADVERSEREACTION

NURSING

RESPONSIBILITIES



Date Ordered:

Feb.21 2011

Generic Name:

Nebulizaton

with

SALBUTAMOL

+ ipratropium q

8 1 amp.

Brand Name:

Activent

Dosage and

Frequency:

1Neb. 1amp

every 8 hours.

Classification:

Symphatomim

etics

>Stimulates

Beta2 receptors

of bronchioles

by increasing

the levels of

cAMP which

relaxes smooth

muscles to

produce

bronchodilation.

> Relief and

prevention of

bronchospasm

in patients withreversible

obstructive

airway disease

or COPD

>Inhalation

and treatment

of acute attackof

bronchospasm

>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,

>Assess cardio-

respiratory

function: B/P,

heart rate and

rhythm and

breath sounds

>Monitor for

evidence of

allergic

reactions and

paradoxical

bronchospasm

DRUG NAME ACTION INDICATION

CONTRAINDI-CATION

ADVERSEREACTION

NURSINGRESPONSIBI-

LITIES



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 butbinds to mu-

opioid receptors

and inhibits

reuptake of

norepinephrine

and serotonin.

>Tramadol is

used for

moderate to

severe pain.

>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.

>Assess patient’s

pain (location,

type, character)

before therapy

and regularlythereafter 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.

DRUG NAME ACTION INDICATION CONTRAINDIC

ATION

ADVERSE

REACTION

NURSINGRESPONSIBI-

LITIES



Date Ordered:

Feb.21 2011

Generic Name:

Dexamethason

e 250 g IV q8

Brand Name:

Decilone

Dosage and

Frequency:

Classification:

Hormones and

related drugs.

>Synthetic

glucocorticoid w/

marked anti-

inflammatory

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

>systemic

fungal infection:

IM injection use

in idiophaticthrombocytopeni

c purpura:

>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 beforetherapy.

>Assess for

possible drug

induced adverse

reaction.

>Monitor renal

status and

function.

>Assess mental

status: Affect,

mood,

behavioral

changes.

>Assess pt’s

and family’s

knowledge on

drug therapy.


ATION

ADVERSE

REACTION

NURSINGRESPONSIBI-

LITIES



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 ofacetylcholine. It

causes a local

and site specific

bronchodilatatio

n by preventing

the increase in

intracellular

cyclic guanosine

mono-

phosphate

which produced

by the

interaction of

acetylcholine w/

the muscarinicreceptors of the

bronchial

smooth

muscles.

Acute

exacerbations of

chronic

obstructive

pulmonarydisease

(COPD). Used

in conjunction

w/ beta-

adrenergic

stimulant for

acute asthmatic

attacks.

Hyper sensitivity

to soya lecithin

or related food

products.

Atropine or anyanticholinergic

derivates.

Dryness of

mouth, throat

irritation or

cough.

>Assess

patient’s

condition before

and after drug

therapy. Monitorpeak expiratory

flow.

>Monitor for

evidence of

allergic

reactions,

paradoxic

bronchopspasm

.

>Assess pt’ and

family’s

knowledge on

drug therapy.

>Inform pt. that

drug is noteffective for

treatment of

acute

bronchopspasm

>Teach pt. the

proper way of

drug

administration.


ATION

ADVERSE

REACTION

NURSINGRESPONSIBI-

LITIES



Generic Name:

doxorubin HCl

Brand Name:

Adriamycin

Injection:

2mg/ml

20mg/m2 IV

once weekly

Classification:

Antineoplastic

s

May interfere

with DNA-

dependent RNA

synthesis by

intercalation

Bladder, breast,

lung, ovarian,

stomach and

thyroid cancers

Patients with hx

of sensitivity

reactions to

drug or its

components

Patients with

marked

myelosuppressi

on induced by

previous

treatment withother antitumor

drugs or therapy

Arrythmias,

leukopenia,

thrombocytopen

ia,

myelosuppressi

om

>Never give

drug IM or SQ

>Monitor CBC

and hepatic

function tests

Monitior ECG

every month

during therapy

Takepreventive

measures

including

(adequate

hydration)

before starting

treatment

If signs of

arrythmias

develop, stop

drug

immediately and

notify prescriber


ATION

ADVERSE

REACTION

NURSINGRESPONSIBI-

LITIES



Generic Name:

mechlorethami

ne Hcl

Brand Name:

Mustargen

Injection: 10mg

vials

o.4 mg/kg

intracavitarily

Classification:

Antineoplastic

s

Cross-links

strands of

cellular DNA

and interferes

with RNA

transcription,cau

sing an

imbalance of

growth that

leads to cell

death.

Hodgkin’s

disease,

malignant

effusions

(pericardial,

peritoneal,

pleural)

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

nausea,

vomiting,

snorexia,

diarrhea,

leukopenia, mild

anemia

thrombocytopen

ia,

agranulocytosis

>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 injectionswhen PLT count

is less than 50,

000/mm3

Monitor pt

closely for bone

marrow

suppression

Give BT for

cumulative

anemia



ACTION RATIONALE



ACTION RATIONALE

>Assess respiratory rate and depth >useful in evaluating the degree of

respiratory distress and /or chronicity of

the disease process .

>Auscultate chest , noting presence

or characteristic of breath sounds,

presence of secretions.

>to identify etiology or precipitating

factors

>Observe characteristics of cough >cough can be persistent but

ineffective, especially if client is elderly,

acutely ill, or debilitated.

>Perform physical and or

psychological assessment

>to determine the extent of the

limitation of the current condition.

ACTION RATIONALE



ACTION RATIONALE

>Encourage adequate rest periods

between activities

>to limit fatigue

>Establish a minimum weight goal

and daily nutritional requirements

>provides comparative baseline for

effectiveness of therapy

>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 theclient about the possible side effects of

the medication.



EXERCISE

Encourage ambulation.Patient will be given deep breathing

exercises to promote lung

expansion. Use an incentive spirometerto promote deep breathing



TREATMENT



•Instruct the client to continue drug therapy as

ordered.

•Inform the client as well as the family the dangers ofnon 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 doctor’s

orders, especially in taking prescribed medications

•Encourage the patient to have followed up visitationsto 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 patient’s illness.

•Continue medication as ordered.

•Instruct to have a follow-up check-up or refer to thephysician if the patient is uncomfortable

•Instruct the client and significant others to report for

any unusualities



This case study has provided us with importantinformation about the patient’s 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. Don’t give up. Learn to rest,

but NEVER QUIT future RN’s! ”



As ONE! Be it in

class or in duty



GROUP 2… so happy

together!!!! :))

case presentation lung ca final

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