lung ca care plan to upload

8/3/2019 Lung CA Care Plan to Upload

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Dates

Patient Initials Room Number:

Allergies: NKA Height: Weight: Living Will? No Power of Attorney? No

Admitting Diagnosis/Chief Complaint:

c/o worsening shortness of breath at rest x3wks following failed

outpatient antibiotic therapy for possible pneumonia

Dx: recurrent malignant right pleural effusion

Vital Signs

9/8/11

@1240

T 98.1 oral P 100 R 20 BP 93/59

Medical History:

Lung mass, smoker x35 years, anxiety, partial hysterectomy,

tonsillectomy

Surgical History:

8/29/: Ultrasound guided thoracentesis of right chest by Dr.

9/7/11: Right VATS (video assisted thoracic surgery) with chemica

and mechanical pleurodisis, pleural biopsy and right chest wallmediport placement by Dr.

Family History:

Lung cancer; various malignancies; father hx of collapsed lung, colon

cancer, and dementia; mother hx ETOH

Health Promotion:

-Teach that smoking increases risk for development of many

pulmonary problems.

-assist pts. Interested in smoking cessation to find an appropriate

smoking cessation program.

Use of substances: Alcohol? Tobacco? Drugs?

Tobacco smoker x35 years

Personal History:

Smoker x35 years; lives alone; has 2 children

Payment source:

Discharge Planning:

Concerns? Lives alone; daughter lives out of town Anticipated needs? Transportation assistance back and fort

to clinic for treatment (chemotherapy)

Resources? No PCPPhysician Orders: NA


2/26

Medication Prep Sheet Dates

edication Name

rade/Generic

eference

Classification

How does it work?

Why is patient

getting it?

Frequency

& Time

Rou

te

Onset/Pe

ak

Relevant

labs/monitoring

Nursing Implications

/ Side Effects

Drug Evaluation

How you know it

worked

olate, Folvite,

vitamin B,

Apo-Folic,

Novofolacid

Folic acid

Antianemics,

vitamins; H2O

soluble

vitamins;

Required for

protein

synthesis &RBC function.

Stimulate

production of

RBC, WBC, &

PLT

Prevention &

tx of

megaloblastic

& macrocytic

anemia

(to prevent

anemia whiletxed with

chemotherap

y)

1mg daily

@0900

PO 30-60

min

1 hour

Plasma folic acid

levels, Hgb, Hct,

& retic count

before &

periodically

during therapy

May decreaseserum conc. of

other B complex

vitamins when

given in high

conc. Doses

Do not confuse folic

acid w/ folinic acid

(leucovorin calcium)

b/c of infrequency of

solitary vitamin

deficiencies, combos

are commonly adm.

Assess for signs of

megaloblastic anemia

(fatigue, weakness,

dyspnea) before &

periodically

throughout therapy

Pt teach: Encourage

diet recomm. For high

folic acidvegetables,fruits, organ meats;

heat destroys folic acid

in foods; urine maybecome intensely

yellow. Notify HCP if

rash occurs..may ind.

Hypersen. Emphasize

importance of F/U

exams and eval

progress.

PO: Antacids given @

least 2hrs after folic

acid

Reticulocytosi

days after begin

therapy

Resolution

symptoms o

megaloblast

anemia


3/26

PO: Folic acid given

2hrs before or 4-6hrs

after cholestyramine.

SE: Dermrash.CNSirritability,difficulty sleeping,

malaise, confusion.

MISCfever

Xopenex,

Xopenex HFA

levalbuterol

Bronchodilators

/Adrenergics

R-enantiomer

of racemic

albuterol. Binds

to beta-2

adrenergic

receptors in

airway smooth

muscle leading

to activation of

adenylcyclase &

increased levels

of cyclic-3', 5'-

adenosine

monophosphate(cAMP).

Increases in

cAMP activate

kinases, which

inhibit the

phosphorylatio

n of myosin &

decrease

intracell. Ca.

Decreased

Bronchospas

m due to

reversible

airway

disease

(short-term

control

agent).

1.25mg

Q6hr WA

@ 0800

1400

2000

0200

neb 10-17

min

90 min

May increase

serum glucose &

decrease serum

K+

Monitor PFT

before initiating

therapy &

periodically

during course to

determine

effectiveness of

med.

Assess lung sounds,

pulse, & B/P before

adm & during peak of

med.

Note amt., color, &

character of sputum

produced.

Observe for

paradoxical

bronchospasm

(wheezing). If

condition occurs,

withhold med & notify

MD immediately.

Pt teach: proper use of

nebulizer; caution pt

not to exceed

recommended does;

consult MD before

taking any OTC meds

or alcohol

concurrently w/ this

therapy. Avoid

smoking & other resp

Prevention or r

of bronchospa


4/26


5/26

Vicodin

Acetaminophe

/hydrocodone

d analgesic

combo

Therap:

antitussive;

opioid

analgesics

Schedule III (in

combo)

Bind to opiate

receptors in

CNS. Alter the

perception of &

response to

painful stimuli

while producing

generalized

CNS

depression:

Suppress cough

reflex via direct

central action

Therap:

Decrease in

severity of

moderate pain.

Suppression ofcough reflex

nonopioid

analgesics in

management

of moderate

to severe

pain.

Antitussive

(usually in

combo

products w/

decongestant

s

g tabs)

PO Q6hrs

prn pain

30-60

min

& lipase

concentrations

Assess B/P,

pulse, &

respirations

before &

periodically

during adm. If

resp rate


6/26

physical &

psychological

dependence &

tolerance. This

shouldntprevent pt from

receiving

adequate

analgesia. If

progressively

higher does are

required,

consider

conversion to a

stronger opioid.

Toxicity &

Overdose: If an

opioid

antagonist is

required to

reverse resp

depression or

coma, naloxone

(Narcan) is the

antidote.

Pt Teach: take as

directed & not to take

more than

recommended amt.

Severe & permanent

liver damage & Renal

damage may result

from prolonged use or

high doses of

acetaminophen.

Instruct on how &

when to ask for & take

pain med. May cause

drowsiness or

dizziness. Call for

assist when

ambulating. Avoid

driving until response

to med is known.

Change positions

slowly to minimize

orthostatic

hypotension. Avoid

concurrent use of

alcohol or other CNS

depressants w/ thismed. Encourage turn,

cough, deep breath to

prevent atelectasis.

Goo oral hygiene,

frequent mouth rinses,

& sugarless gum or

candy may decrease

dry mouth.

SE: confusion,

dizziness, sedation,


7/26

resp depression,

hypotension,

constipation, nausea,

vomiting, sweating,

blurred vision,

dyspepsia (indigestion)

Tylenol

acetaminophe

n) w/ Codeine

#3

Tylenol;

PAP; Aspirin

Free Pain

elief; Feverall

cetaminophen

Antipyretics;

nonopioid

analgesics

Inhibits

synthesis of

prostaglandins

that may serve

as mediators of

pain and fever,

primarily in

CNS.

Mild pain 1 tab

(300mg

acetamin

ophen/

30mg

Codeine)

Q4hr

PRN pain

PO 0.5-1 hr

1-3 hr

Eval hepatic,

hematologic, &

renal func

periodically

during

prolonged, high-

dose therapy

May alter results

of blood glucose

monitoring.

Increased serumbilirubin, LDH,

AST, ALT, &

PT may indicate

hepatotoxicity

Toxicity &

Overdose: If

OD occurs,

acetylcysteine

(Acetadote) is

When combined w/

opioids do not exceed

max recommended

daily dose of

acetaminophen

PO: adm w/ full glass

of water. May be

taken w/ food or on

empty stomach.

Pt teach: take as

directed. Use of>4grams/day may lead

to hepatotoxicity,

renal, or cardiac

damage. Avoid alcohol

& NSAIDS. Inform

DM pts that

acetaminophen may

alter glucose

monitoring. Check all

OTC labels. Consult

Relief of mild


8/26

antidote.

Assess overall

health status &

alcohol usage

before adm. Pts.

Who are

malnourished or

chronically

abuse alcohol

are at higher

risk of

developing

hepatotoxicity w/

chronic use of

usual doses.

Assess amt,

frequency, &

type of drugs

taken in pts self-

medicating, esp

w/ OTC drugs.

Combined doses

of

acetaminophen

& salicylatesshouldnt exceed

recommended

dose of either

drug given

alone.

Assess pain,

location, &

intensity prior to

& 30-60min

HCP if discomfort not

relieved by routine

doses.

SE: Hepatic failure,

hepatotoxicity

(overdose), renal

failure (high

doses/chronic use).

Neutropenia;

pancytopenia;

leukopenia; rash


9/26

after adm.

Paveral

Codeine

Pharm: opioid

agonists

Therap:

allergy, cold,

and cough

remedies,

antitussives,

opioid

analgesics

Schedule II, III,

IV, V (depends

on content)

Binds to opiate

receptors in

CNS. Alters

perception of &

response to

painful stimuli

while producing

generalized

CNS

depression.

Decreasescough reflex &

GI motility.

Management

of mild to

moderate

pain.

Unlabeled

use:

management

of diarrhea.

1 tab

(300mg

acetamin

ophen/

30mg

Codeine)

Q4hr

PRN pain

PO 30-45

min

60-120

min

May cause

increase plasma

amylase & lipase

conc.

Toxicity & OD:

Antidotenaloxone

(Narcan)

Assess B/P,

pulse, &

respirations

before &

periodically

during adm. If

resp rate


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type, location, &

intensity of pain

prior to & 1hr

(peak) following

adm.

Prolonged use

may lead to

physical &

psychological

dependence &

tolerance. This


receiving

adequate

analgesia. If

progressively

higher does are

required,

consider

conversion to a

stronger opioid.

PO: may be adm

w/food or milk to

minimize GI irritation

Instruct on how &

when to ask for & take

pain med. May cause

drowsiness or

dizziness. Call for

assist when

ambulating. Avoid

driving until response

to med is known.

Change positions

slowly to minimize

orthostatic

hypotension. Avoid

concurrent use of


depressants w/ this

med. Encourage turn,

cough, deep breath to

prevent atelectasis.

Goo oral hygiene,

frequent mouth rinses,

& sugarless gum orcandy may decrease

dry mouth.

SE: confusion,

sedation, blurred

vision, hypotension,

constipation, nausea,

vomiting, sweating,

urinary retention,

flushing.


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Duramorph,

Morphitc,

Astramorph,

DepoDur,

Embeda,

Avinza, MS

Contin,

Oramorph,

Roxanol

Morphine

Pharm: Opioid

agonist

Thera: opioid

analgesics

Binds to opiate

receptors in

CNS. Alters

perception of &

response to

painful stimuli

while producing

generalized

CNS

depression.

Therap Effects:

decrease in

severity of pain.

Sched II

Sever pain;

pulmonary

edema.

2-4mg

IVP

Q2hrs

PRN pain

IVP Onset:

rapid

Peak:

20min

May increase

plasma amylase

& lipase levels

Toxicity &

Overdose:

Antidotenaloxone

(Narcan)

Assess type,

location, &

intensity of pain

prior to and

20min after IV

adm.

Assess B/P,

pulse, &

respirations

before &

periodically

during adm. If

resp rate


12/26

opioid use

exceeds 2-3 days,

unless

contraindicated.

Prolonged use

may lead to

physical &

psychological

dependence &

tolerance. This


receiving

adequate

analgesia.

Progressively

higher doses

may be required

to relieve pain w/

long-term

therapy.

doses.

Med should be d/cedgradually after long-

term use to prevent

w/drawal symptoms.

Direct IV: Solution is

colorless; do not adm

discolored solution.

DILUENT: Dilute w/

at least 5ml sterile

water or 0.9% NaCl

for injection.

CONCENT: 0.5-

5mg/ml. RATE: High

AlertAdm 2.5-15mgover 5 min. Rapid

adm may lead to

increased resp

depression,

hypotension, and

circulatory collapse.

Syringe

incompatibility:

meperidine,

pantoprazole,thiopental

Pt Teach: instruct

how and when to ask

for pain med. High

Alert: Instruct family

not to adm PCA doses

to sleeping patient.

May cause drowsiness

or dizziness. Call for


13/26

assist when amb.

Change positions

slowly to minimize

orthostatic

hypotension. Avoid

concurrent use of


depressants w/ this

med. Encourage pts

who are immobilized

or on prolonged

bedrest to turn, cough,

and deep breathe every

2hr to prevent

atelectasis. Emphasize

import. Of aggressive

prevention of

constipation w/ use of

morphine

SE: confusion,

sedation, dizziness,

blurred vision, resp

depression,

hypotension,

constipation, itching,

sweating, flushing,N&V

Zofran

Ondansetron

Pharm: 5-HT3

antagonists

Thera:

antiemetic

Blocks effects of

serotonin at 5-

HT3-receptor

Prevention of

nausea &

vomiting

associated w/

chemotherap

y or

radiation

therapy

4mg IV

Q6hr

PRN

nausea

IV Onset:

rapid

Peak:

15-

30min

May cause

transient

increase in

serum bilirubin,

AST, & ALT

levels

Assess for

nausea,

Don Not confuse

Zofran (ondansetron)

w/ Zosyn

(piperacillin/tazobacta

m).

1st

dose is adm prior to

emetogenic event

(vomiting).

Prevention

nausea & vom

associated w/ in

& repeat cours

emetogenic ca

chemotherap

Prevention of p

op nausea &


14/26

sites (selective

antagonist)

located in vagal

nerve terminal

& the

chemoreceptor

trigger zone in

CNS.

Therap. Effects:

decreased

incidence &

severity of

nausea &

vomiting

following

chemotherapy

or surgery

Prevention &

tx of post-op

nausea &

vomiting.

vomiting,

abdominal

distention, &

bowel sounds

prior to & after

adm.

Assess for

extrapyramidal

effects

(involuntary

movements,

facial grimacing,

rigidity,

shuffling walk,

trembling of

hand)

periodically

during therapy

Direct IV: Adm

undiluted (2mg/ml)

immediately before

induction of anesthesia

or post-op if nausea &

vomiting occur shortly

after surgery. RATE:

Adm. Over at least 30

seconds and preferably

over 2-5min.

Syringe

incompatibility:

droperidol.

Pt teach: take as

directed; advise to

notify HCP

immediately if

involuntary movement

of eyes, face, or limbs

occurs.

SE: Headache;

constipation; diarrhea;

dry mouth; elevatedliver enzymes;

extrapyramidal

reactions

vomiting.

Ambien,

Ambien CR,

Edluar,

Zolpimist

Zolpidem

Schedule IV

Sedative/hypnot

ics

Produces CNS

depression by

Insomnia 10mg at

bedtime

PRN

sleep

PO Onset:

rapid

Peak:

30min-

2hrs

Assess mental

status, sleep

patterns, and

potential for

abuse prior to

adm. Prolonged

use of >7-10 days

Before adm, reduce

external stimuli &

provide comfort

measures to increase

effectiveness of med.

Protect pt from injury.

Relief of insom


15/26

binding to

GABA

receptors.

Thera Effects:

Sedation &

induction of

sleep.

may lead to

physical &

psychological

dependence.

Limit amt of

drug available to

pt.

Assess alertness

@ time of peak

effect. Notify

MD if desired

sedation not

occur.

Assess for pain.

Medicate as

needed.

Untreated pain

decreases

sedative effects.

Raise bed side rails.

Assist w/ amb.

PO: Tablets should be

swallowed whole w/

full glass of H2O. For

faster onset of sleep, do

not adm w/ or

immediately after a

meal.

Pt Teach: take as

directed. Do not take

unless able to stay in

bed a full night (7-8

hrs) before being

active again. B/c

rapid onset, advise to

go to bed immediately

after adm. May cause

daytime drowsiness or

dizziness. Caution that

complex sleep-related

behaviors may occur

while asleep. Notify

MD immed. if S/S of

anaphylaxis. Avoid

use of alcohol or otherCNS depressants.

SE: daytime

drowsiness, dizziness,

anaphylactic reactions,

tolerance, amnesia,

behavior changes,

drugged feeling,sleep-driving


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16

Admitting Diagnosis, Contributing Medical Diagnoses, & Surgical Procedure Outlines:

1. Admitting Diagnosis: Recurrent malignant right pleural effusion S/P thoracentesisDefinition:

pleural effusionfluid in the thoracic cavity between the visceral & parietal pleura. It may be seen

on a chest radiograph if it exceeds 300ml.

malignant diseaseCancer. A disease, including but not limited to cancer, in which progress is

extremely rapid & generally threatening or resulting in death within a short time.

ThoracentesisInserting a needle through the chest wall & into the pleural space, usually to remove

fluid for diagnostic or therapeutic purposes. Disadvantage: recurrent pleural effusion

How diagnosed: chest x-rays; ultrasounds; PET scans; CT chest; thoracentesis; cytology

Nursing Care:

Respiratory function is monitored by auscultation, observation of breathing pattern, and SPO2. The

patient is positioned in the high Fowler position to facilitate chest expansion. Rest is encouraged. Deepbreathing using incentive spirometry is encouraged every 1 to 2 hr to prevent atelectasis. To reduce

discomfort when coughing, the patient should splint the chest with a pillow and administer analgesic

drugs.Prescribed medical regimens are carried out, with treatment directed at the underlying cause, and the

patient's responses evaluated. Monitor for S/S of infection at puncture site s/p thoracentesis

Client Education:

Notify HCP if increase shortness of breath, need for pain meds. Use of IS every hour while awake.

Rest is recommended. Call for assistance OOB. Patient should splint chest with pillow when coughing.

Monitor for redness, drainage, or increase pain to puncture site s/p thoracentesis

Signs & Symptoms of Complications:

Shortness of breath; increase pain; fatigue; infection at puncture site s/p thoracentesis

Reference:

Ignatavicius, D.D., & Workman, M.L. (2010).Medical-surgical nursing: Patient-centered collaborative

care. St. Louis, MO: Saunders Elsevier.

Venes, D., & Taber, C.W. (2009). Tabers cyclopedic medical dictionary. Philadelphia: F.A. Davis Co.

2. Surgical Procedure: Right VATS w/ pleurodesis, Pleural bx w/ Mediport Placement


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Definition:

VATSVideo assisted thoracic surgery. A chest tube is inserted to drain the fluid and administer a

sclerosing agent, which causes an inflammatory response, causing the pleura and chest wall to stick together.

This inflammatory response is called pleurodesis and will prevent further pleural effusions. A biopsy of the

pleura is collected for further evaluation of tissue. This procedure can be done under local anesthesia or in the

OR under general anesthesia.

Mediport placementMediports are implanted devices that allow for long-term IV access, such as use

during chemotherapy. Mediports should be accessed and flushed at least every 4-6 weeks.Periodic flushing maintains patency. To access, a 20 gauge Huber needle is most commonly used and

sterile technique is used. Nursing care: monitor site for swelling, redness, drainage, pain, or tenderness.

S/S of complications: swelling at mediport site when flushing with saline; unable to flush port; able to

flush but no blood return.

Nursing Care Pre-op:

Explain the procedure to patient. Signed consents by MD and patient. Adm. drugs as ordered to

promote comfort. Encourage patient to voice feelings of anxiety and other concerns about

treatment.

Nursing Care Post-op:

Priority nursing care of a chest tube is maintain intact of drainage system, promote comfort, chest

tube patency, and prevent potential complications. Monitor V/S and respiratory status at least every 30 minutes

until the effects of the IV drugs have resolved. Then, V/S are monitored every 4 hours for 24 hours. Assess

chest tube drainage characteristics and amount. Complete respiratory assessment should be performed every 2

hours, while observing for s/s of respiratory distress. Administer analgesics as needed for pain. Assess lung

sounds over chest tube site which may be diminished. Maintain chest tube dressing clean, dry, intact, and

occlusive. Assess for SQ emphysema by palpating around chest tube insertion site. If chest tube is to

suction, look for bubbling in the suction chamber. Observe for tidaling in water-seal chamber. Maintainwater level at 2 cm mark. Monitor for any air leaks. The fluid in chamber one must never fill to the

point that it comes into direct contact with either the tube draining from the patient or the tube connecting this

chamber to chamber two. If the tubing from the patient enters the fluid, drainage stops and can lead to a

tension pneumothorax. (Ignatavicius & Workman, 2010)

Client Education:

Turn, cough, deep breath, and use of incentive spirometry. Use pillow to splint chest tube site while

coughing and deep breathing. Keep drainage system below chest level in an upright position. Avoid kinks

in chest tube. Notify HCP if shortness of breath or increase pain or pressure occurs. Instruct patient

about no heavy lifting greater than 10lbs.



18/26

18

Sudden increase pain and pressure indicate complications. Notify MD immediately if any of the

following occur: SPO2 70ml/hour or

becomes bright red; if chest tube disconnects from drainage system or becomes dislodged from

patients chest; during 1st

24 hours, drainage in tube stops.

Reference:




Lynn, P.B., & Taylor, C. (2008). Taylors clinical nursing skills: A nursing process approach. Philadelphia:

Lippincott Williams & Wilkins.

3. Contributing Diagnosis: Stage IV adenocarcinoma of the lungDefinition:

Lung cancer is the leading cause of death in both men and women. Adenocarcinoma is the most

common type of lung cancer. It is slow-growing and can take years to develop symptoms, which

include shortness of breath, wheezing, chest pain, decrease appetite, unintentional weight loss, fatigue

and weakness, persistent cough, dysphagia, hoarseness, shoulder pain, bloody sputum, bone pain or

tenderness, neck and face swelling, recurrent pneumonia or bronchitis. Consult with MD if any symptoms

persist more than two weeks. This type of non-small cell cancer develops at the periphery of the lung and the

cells form glandular patterns that are recognizable. Gross appearance is identified with the three Ps

peripheral, pigmented and puckered (Lung Adenocarcinoma, 2011). Cigarette smoking causes most lung

cancer types, and is directly related to the number of cigarettes smoked per day and how long the patient has

smoked. Secondary risk factors include age, family history, and exposure to secondhand smoke, mineral

and metal dust, asbestos, formaldehyde, and radiation.

How diagnosed:

Least invasive procedures include chest x-ray, sputum sample, bone scan, CT scan and MRI of the

chest, PET scan, PFTs, ABGs, lung cancer tumor markers, and CBC. More invasive procedures include

bronchoscopy with biopsy and/or bronchial brushings, CT-guided biopsy, thoracoscopy performed through a

VATS, and thoracentesis.. According to the New England Journal of Medicine, screening with the use of

low-dose CT reduces mortality from lung cancer.

Staging of cancer is determined after reviewing results of all tests and procedures done. Staging of lung

cancer determines the exact cancer location and its degree of metastasis. It is also correlated to the

survival rate. During Stage I, the tumor is small and hasnt spread to the lymph nodes. Once the cancer has

spread the local lymph nodes, it is considered Stage II. Stage III includes metastasis to nearby tissues and

distant lymph nodes. In Stage IV, the cancer has spread to other organs, such as the bone, liver, small

intestine, and brain.

Once the stage is determined, treatment options are discussed between the doctor and patient.

Surgery is usually the treatment of choice and can cure most patients with stage I and II. For Stage


19/26

19

III and IV, which are frequently aggressive and widespread, chemotherapy and radiation therapy are

recommended. Therapy goals in patients with stage IV is prolonging and improving the quality of life.

Nursing Care:

Use aseptic technique when indicated. Inspect mouth and perform oral care when needed using a

soft toothbrush. Assist patients in smoking cessation. Assess for interference with the patients ADL

due to shortness of breath or pain. Assess respiratory status when patient experiencing shortness of breath or

altered mental status. Apply humidified supplemental oxygen to maintain SPO2 >90%. Teach skin care tothose patients undergoing radiation therapy. Assess sputum quantity and quality. Breath sounds may

change with the presence of a tumor. Superior vena cava syndrome is an emergency and is caused by

pressure of the tumor in or around the vena cava. Provide psychosocial support. Cancer patients may

experience fear of patient and death, anxiety, guilt, shame, and helplessness. The most important nursing

intervention during chemotherapy is preventing extravasation. In patients with neutropenia, temperature

>100 should be report to the MD immediately.

Client Education:

Teach older adults to report if they experience the seven warning signs of cancer: Changes in bowel

or bladder habits; A sore that doesnt heal; Unusual bleeding or discharge; Thickening or lump in the breast;

Indigestion or dysphagia; Obvious change in a wart or mole appearance; Nagging cough or hoarseness. Diet:

Bland and avoid spicy foods. Oral care: use soft toothbrush. Allow the patient to express his or her feelings

about the diagnosis of cancer and treatment options. Refer patients and family members to local cancer

support groups. Encourage smokers to quit because lung cancer risk decreases dramatically during the

first year of cessation.


Metastasis; side effects of surgery, chemotherapy, or radiation therapy

Reference:

College of American Pathologists. (2011). Lung cancer: Lung adenocarcinoma. Retrieved September 12,

2011, from http://www.cap.org/apps/docs/reference/myBiopsy/LungAdenocarcinoma.pdf

Fretz, P., & Hughes, J. (n.d.). Lung Adenocarcinoma.Lung Adenocarcinoma. Retrieved September 12, 2011

from http://www.lungadenocarcinoma.co



Lung cancernon-small cell: MedlinePlus Medical Encyclopedia. (n.d.).National Library of Medicine

National Institutes of Health. Retrieved September 12, 2011, from http://www.nlm.nih.gov/medlineplus

Reduced Lung-Cancer Mortality with Low-Dose Computed Tomographic Screening. [Entire issue]. (2001).

New England Journal of Medicine, 365 (5). Retrieved on September 12, 2011, from http://www.nejm.org


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Winters, R. (n.d.). Focused on HealthNovember 2008Get the Facts: Lung CancerMD Anderson Cancer

Center. Cancer Treatment and Cancer ResearchMD Anderson Cancer Center. Retrieved September 12,

2011, from http://www.mdanderson.org/publications/focused-on- health/issues/2008-november/focused-on-

health-november-2008-get-the-facts-lung-cancer.html


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Neuro-Muscular

Activity: ___BR ___up ad lib ___BRP

___ up with assistance

Ambulatory: Y/N assistance? ________

Gait: __________ Posture: ___________

Assistive devices: __ walker ___ cane

__wheelchair other: ______________

ROM: __ other: ____________________

Extremity strength: RUE ___ LUE ___

RLE ___ LLE ____

Exercise: _________ Frequency: ______

Physical therapy: ___________________

Joint swelling/deformity _____________Other: describe: ____________________

Psychologica

l

Affect __________ LOC ____________

Vision: WNL ____ Other:____________

Hearing: WNL ___ Other:___________

Speech: WNL ____ Other:___________

Primary language: _________________

Support persons: __________________

__________________________________

Occupation: _______________________

Cultural considerations: ____________

__________________________________

Coping skills: _____________________

Prosthesis: ________________________Other: describe: ___________________

Card

iovascular

Heart Rate: ______ Rhythm: _________

Apical Rate: ______

Sounds auscultated: S1/S2/S3/S4

Peripheral Pulses: Radial (R)___ (L)___

Pedal (R) ___ (L)___

Edema: extremities? ________________

sacrum? _____________

Capillary refill: Upper ____Lower ____Telemetry: ________________________ S

afet

y

Age related considerations: __________

History of: Seizures?____ Falls?______

Restraints? _______________________

Bed rails up? ______ x_____

Call bell in reach? _________

Bed in low position?________

Other: describe: ___________________

____________________________________________________________________

Respiratory/

Oxygenation

Breath sounds: _____________________

Resp Rate:___Depth: ____ Rhythm: ___

Oxygen: ___________________________

SOB?____ Dyspnea?_____ Cough?____

Sputum?___________________________Other: describe: ____________________

___________________________________Integumentary/S

kin

Color: _________ Temp: ___________

Turgor: ________ Moisture: _________

Lesions? __________________________

Wounds? _________________________

Wound care orders? __________________________________________________

__________________________________

Gastrointestinal

Appetite: ___________ I & O? ________

Diet: ______________________________

Supplement:________________________Oral cavity: ________________________

Abd: Skin Color______Contour_______

Bowel sounds: ______________________

Last BM: _______ Usual pattern:______

Consistency:________Distention?______

Peristalsis?____ Palpation: ___________ IVaccess

IV site: ____________ Gauge: ________

Insertion date: _____________________

IV Fluids: ________________________IVPB:____________________________

__________________________________

Describe site: ______________________

__________________________________

Genitourinary

Continent? ____ Incontinent? _________

Assistive devices? ___________________

Urine character? _______ Color? ______

Frequency? ______Urgency? _________

Burning? _________ Dialysis?_________

Catheter? Type: ____________________Spirituality/

Sexu

ality

Religion___________Concerns?_______

Any beliefs that affect care? _________

Describe: _________________________

Major loss?______Mood change?_____

Sexual dysfunction: ________________

Concerns?________________________

Comfort&

Pain

Pain?______ Where?________________

Duration?__________ Quality?________

Relieving factors?___________________

Aggravating factors?________________

Pain scale:________ Reassess:_________

General

Survey

Awake?___ Alert?____ Oriented?_____

Assistive devices? __________________

Distress? _________ Injury? _________

Speech/hearing deficits?_____________

DNR on chart? Yes or No

Clinical Day 1: Client Initials: _______ Date: __________________________


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22

Neuro-Mu

scular

Activity: ___BR ___up ad lib ___BRP___ up with assistance

Ambulatory: Y/N assistance? Yes w/assist

Gait: unsteady Posture: ___________

Assistive devices: __ walker ___ cane

__wheelchair other: ______________

ROM: intact other: ____________________

Extremity strength: RUEstrong LUE strong

RLEstrong LLE strong

Exercise: _________ Frequency: ______

Physical therapy: __NO______________

Joint swelling/deformity NO___________Other: generalized weakness noted. P

sychological

Affect __________ LOC _AAOx4____

Vision: WNL ____ Other:____________Hearing: WNL ___ Other:___________Speech: WNL ____ Other:___________Primary language: _English_______

Support persons: _Daughter who is driving

in from Alabama today___

Occupation: retired____________

Cultural considerations: _Catholic_

__________________________________

Coping skills: _good, but w/anxiety_

Prosthesis: ________________________Other: describe: ___________________

Ca

rdiovascular

Heart Rate: __100___ Rhythm: NSR___

Apical Rate: __100__Sounds auscultated: S1/S2/S3/S4

Peripheral Pulses: Radial (R)_+1 (L)+1_

Pedal (R) +1 (L)+1_

Edema: extremities?NO Sacrum? No

Capillary refill: Upper


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Student Client initials: . Date:

Key Problem #1

neffective Breathing R/T imbalance b/w

O2 supply & demand, pain AEB:

Presence of right chest tube; new

dx of lung Ca, SOB at rest &

w/speaking; breath sounds

diminished RLL. IS q2hrs WA;

Xopenex nebs q6hr WA; hx

smoker

9/8: CXRright pleural effusion

I dont know where this fits

Key Problem #5

Ineffective denial r/t complicated

grieving process AEB:

Anxiety

Voices concern about fear

of the unknown and death

Contradictory at times

regarding ADLs and tx.

c/o insomnia at night:

Ambien 10mg po at

bedtime for sleep

Reason for needing healthcare: c/o worsening SOB at rest x

3weeks w/ unsuccessful tx for poss. Pneumonia

Med Dx: malignant Right pleural effusion & adenocarcinoma

of the lung

Sx: 9/7Right VATS w/ pleurodesis, pleural bx, with

mediport placement. 8/29thoracentesis

Key assessments: labs (alb 1.9; WBC 14.9), V/S, SPO2,

telemetry, chest tube output, pain, SOB at rest; CXR; PET scan

Key assessments:

Key Problem # 2

mbalanced Nutrition: less than body

equirements r/t poor appetite AEB:

c/o decrease appetite and recent

weight loss.

Low serum albumin of 1.9.

Meal intake less than 50%.

Zofran 4mg IVP q6hr PRN nausea

Vitamin B-12 1000mcg IM x1 dose

on 9/8/11

Folic acid 1mg po daily

Key Problem #6

Risk for infection r/t invasive

procedure AEB:

s/p right chest tube

placement

perform wound care using

sterile technique.

Patient teaching of good hand

washing.

9/7/11: Zinacef 1.5grams

IVPB on call to OR

Serum WBC elevated at 14.9

Key Problem #3

Chronic pain r/t metastatic Ca, tumor

progression & related pathology AEB:

c/o pain Right flank pain

w/respiration

Norco 7.5/7.5mg po q6hr PRN pain

Morphine 2-4mg IVP q2hr PRN

pain

Difficulty changing positions and

ambulating

Key Problem #4

Self-deficit and activity intolerance r/t pain & SOB

AEB:

Need for assistance when ambulating and

ADLs

Presence of chest tube s/p Right VATS with

pleurodesis

SOB at rest

Fatigues easily

Teaching/Learning Needs: Disease

process & POC

Strengths: cooperation

Cultural Assessment: 59 yrs. old

white female; catholic; lives alone

SLOPPY COPY


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Client initials Date

Reason for needing healthcare: c/o worsening SOB at

rest x 3weeks w/ unsuccessful tx for poss. pneumonia

Med Dx: malignant Right pleural effusion &

adenocarcinoma of the lung

Sx: 9/7Right VATS w/ pleurodesis, pleural bx, with

mediport placement. 8/29thoracentesis

Key assessments: labs (alb 1.9; WBC 14.9), V/S, SPO2,

telemetry, chest tube output, pain, SOB at rest; CXR; PET

scan

ey Problem # 1

urs Dx: Ineffective Breathing R/T imbalance

/w O2 supply & demand, pain

EB: presence of right chest tube; new dx of

ng Ca, SOB at rest & w/speaking; breath

ounds diminished RLL.

utcomes: lung sounds will be clear & equal

lat; pt will not experience any complications

t chest drainage system or respiratory distress.eport ability to breath comfortably

terventions: Assess resp rate and depth;

ssess breath sounds. Perform complete

ssessment of closed chest drainage system

cluding presence of air leaks, check suction

ontrol, & correct fluid level, assess amt & type

f fluid drainage. Position to facilitate

reathing. Adm o2 as needed. Assess for SQ

mphysema at CT site. Keep CT below patients

hest level and in upright position. Monitor for

ubbling in the suction chamber. Encourage IS

BR: SQ emphysema at CT site could indicate

mproper tube placement or air leak. The

rainage collection system must be positions

elow the tube insertion site so that drainage

an move out of tubing and into collection

evice. Gentle bubbling in the suction chamber

dicates that suction is being applied to assist

rainage. Measurement allows for assessing

ffective therapy.

val: maintained adequate SPO2>92% on room

r. Performed IS Q2hrs WA.

Key Problem #3

Nurs Dx: Chronic pain r/t metastatic Ca, tu

progression & related pathology

AEB: c/o pain

Outcomes: Pt. will use a self-report pain t

to identify current pain level and est. a

comfort-func. goal. Notify nurse promptl

pain greater than the comfort-func goal o

occurrence of adverse effects.

Interventions: Assure that the client recei

attentive analgesic care; Perform

comprehensive assessment of pain, includ

location, characteristics, onset & duration

frequency, quality, intensity or severity, a

precipitating factors. Recognize oral rout

preferred for pain management.

EBR: comprehensive assessment of pain i

critical to determine the underlying cause

pain and effectiveness of tx. It may also r

new acute pain etiology. Pain is the 5th V

The least invasive route of adm (oral) cap

of providing adequate pain control is

recommended.

Eval: calls nurse when pain is reaching

intolerable level.

Key Problem # 2

Nurs Dx: Imbalanced Nutrition: less than body

requirements r/t poor appetite

AEB: c/o decrease appetite and recent weight loss. Labs:

Alb 1.9 (low)

Outcomes: Pt will consume adequate nourishment and be

free of signs of malnutrition. Alb WNL (3.3-5g/dl).

Improve nutritional status. Pt with identify nutritional

requirements and recognize factors contributing to poor

appetite.

Interventions: assess pts food preferences; Avoid

interruptions during mealtimes. Determine time of daywhen pts appetite is the greatest. Adm pain meds as

needed before meal. Assess for dehydration and diarrhea.

Continue diet as tolerated and medically appropriate;

then, CIB TID w/meals.

EBR: The presence of pain decreases appetite.

Dehydration is most common fluid &electrolyte imbalance

in older adults.

Eval: Pt consumes 50-60% of meal tray contents. Increase

appetite. Pt reports decrease appetite d/t worries and

anxiety of new cancer diagnosis.

Teaching/Learning Needs:Disease process &

Strengths: cooperation

Cultural Assessment: 55 yrs. old white fema

catholic; lives alone

FINAL NCCM with Nursing Care Plan


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NCCM & Nursing Care Plan Reference List

TEXTBOOKS:

Ignatavicius, D.D., & Workman, M.L. (2010).Medical-surgical nursing: Patient-centered collaborative care. St. Louis, MO: Saunders Elsevier.

Lynn, P.B., & Taylor, C. (2008). Taylors clinical nursing skills: A nursingprocess approach. Philadelphia: Lippincott Williams & Wilkins.


JOURNALS:

Reduced Lung-Cancer Mortality with Low-Dose Computed Tomographic Screening. [Entire issue]. (2001). New England Journal of Medicine, 365(5). Retrieved on September 12, 2011, from http://www.nejm.org

Winters, R. (n.d.). Focused on HealthNovember 2008Get the Facts: Lung CancerMD Anderson Cancer Center. Cancer Treatment and

Cancer ResearchMD Anderson Cancer Center. Retrieved September 12, 2011, from http://www.mdanderson.org/publications/focused-o

health/issues/2008-november/focused-on-health-november-2008-get-the-facts-lung-cancer.html

OTHER SOURCES:

College of American Pathologists. (2011). Lung cancer: Lung adenocarcinoma. Retrieved September 12, 2011, from

http://www.cap.org/apps/docs/reference/myBiopsy/LungAdenocarcinoma.pdf

Fretz, P., & Hughes, J. (n.d.). Lung Adenocarcinoma.Lung Adenocarcinoma. Retrieved September 12, 2011, from

http://www.lungadenocarcinoma.co

Lung cancernon-small cell: MedlinePlus Medical Encyclopedia. (n.d.).National Library of MedicineNational Institutes of Health. Retrieved

September 12, 2011, from http://www.nlm.nih.gov/medlineplus


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lung ca care plan to upload

Documents