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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 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.

DESCRIPTION OF HEALTH CONDITION

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.

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 Catholic

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

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 given afforded 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 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

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 hadnt 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


didnt have any serious complications until he reaches the age of 65 where he experienced having severe cough that soon became 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.

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.

Sigmund Freuds Psychosexual Stages of Development:

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

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 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.

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 XXXs 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 Filipinos 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 XXXs life on Gods hand and prepared themselves in accepting whatever will happen to patient

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

Breakfast 2-3 tbsp. soup glass of water

Lunch 3-4 tbsp. soup glass of water

Dinner 2-3 tbsp. soup glass 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

day, with exception to coffee maintained and beverages. intravenous fluids

through and

supported by oral fluid intake. Before the illness, patient XXX Previously, patient XXX weighs

weighs about 65 kilograms.

about 40 kilograms, due to his


unusual eating habits and

having difficulty swallowing.

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 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 He takes a bath 1-2

DURING
HOSPITALIZATION His relative provides

times a day with Luke


warm water.

sponge bath to him.

He brushes his teeth


every after meal. He can change and wear clothes or dress if ever he wants.

He brushes his teeth


irregularly. His wife changes his cloth or any available relatives.

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.

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

Integumenta ry Skin
Inspection

- brown - even in overall skin color - presence of paleness of the skin

-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

- poor skin turgor - dry, warm

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

- pale nail beds - clubbing of fingers

Head

Skull & Face


Inspection -

- 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

Eyes & Vision

- 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

Ears & Hearing Inspection

- 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

Nose & Sinuses Inspection

- nose is symmetrical in shape and same - normal in color with face

- patient can breathe with one nostril and the other is occluded
- no presence of discharge - no presence of bumps and tenderness

Palpation

no pain reported - non tender sinuses

- normal

Mouth & Orophar ynx

- no presence of lesions - pink, moist oral mucosa - no dentures

- normal

- cough reflex is weaker Inspection

- 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

Neck Neck muscle s Lymph nodes of the neck Inspection

- symmetrical but weak in strength - symmetrical muscles movement of neck

- normal

lymph nodes are non palpable Palpation

- normal

Trachea

Inspection

trachea is in midline position

- 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

Thyroid gland Palpation

Thorax & Lungs Chest shape & size

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

usually the result of consolidation or bronchial obstruction

* Janet Weber, Jane H. Kelley; Health Assessment in Nursing 3rd Edition 2007 Chapter 16 p. 312

- dullness present Percussion

- 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

Cardiovascular & Peripheral Vascular System Heart (Sounds) Auscultation

- S1 corresponds with each carotid pulsation. S2 immediately follows after S1 - no extra heart sounds and murmurs

Central vessels (carotid arteries & jugular vein) Palpation

- equal in pulse rate, rhythm of - normal carotid arteries, and amplitude of 2+

- 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

normal findings in an elderly person

* Janet Weber, Jane H. Kelley; Health Assessment in Nursing 3rd Edition - Chapter 30 p. 856

Breast & Axillae Breast size, symmetry & contour/sha pe Inspection

- breasts are relatively - normal equal

Palpation Nipples size, shape, position, color, discharge & lesions Axillary, subclavicul ar & supraclavic ular lymph nodes

no presence of hardness in any area

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.

Abdomen: Abdominal contour, symmetry

sunken observed

abdomen

is - a scaphoid (sunken) abdomen may be seen with severe wieght loss


* Janet Weber, Jane H. Kelley; Health Assessment in Nursing 3rd Edition 2007 - Chapter 20 p. 441

Inspection

- symmetrical, no presence of - normal scars, lesions

slight pulsation abdominal aorta in epigastric region

of - normal the

Palpation

Bowel sounds Auscultation

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

Musculoskeletal System: Muscle

Inspection

Bones
Inspection

- no deformities & fractures


- exaggerated thoracic curve

- 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

Non tender joints

-normal

Neurologic: Mental status Inspection

Level of conscious ness Inspection

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

can read a printed writing at 14 inches without difficulty

-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

tongue movement is symmetrical and smooth and strength is bilateral

- normal

Reflexes

Deep tendon reflex

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 Inspection Patellar reflex (knee-jerk reflex)

Triceps reflex

Patellar reflex (kneejerk reflex)

Achilles reflex

both foot has plantar flexion

Achilles reflex

Motor functions

Inspection
-

no tremors seen gait is slow and has bentforward appearance

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

having difficulties of rapid alternating movements

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

pubic hair is thin.


penis and testes size decreased no swelling and no masses

normal findings in an elderly person

* 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

you breathe out.

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

PREDISPOSING FACTORS -Gender Age: 65 y/o

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

Passage of Cigarette Smoke to lower respiratory system Nicotine Tars Carbon Monoxide Ability to Phagocytize inhaled Foreign Particles

Goblet Cells

Mucocilliary Clearance System Impairement

Ineffective Cough Reflex

Impaired Alveolar Macrophages

Chronic irritation and exposure of epithelial tissue to smoking

Vulnerability of epithelial tissue to irritants and carcinogens


Interruption of Normal cells

Exposure / inhalation of infected aerosol through droplet Inhaled nuclei lodge in alveoli Binding of bacterial cell wall to macrophage

Activation of normal cancer cell

Primary growth of tumor in the epithelial tissue


- Desquamation of cells -Hypersecretion of mucus -Hyperplasia of the basal cells -Metaplasia of normal Respiratory epithelium

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 to recognize cancer cell as foreign body


Progression and proliferation of cancer cells

Patient stopped for smoking 2 years ago (2008)

Progression of tubercle bacilli

Formation of granuloma Increased tumor size Drainage of necrotic material into the tracheobronchial tree

Obstruction of the bronchus due to tumor

Cancer cell detached from primary tumor

Scar formation Migrate via lymph nodes or blood circulation Full blown immunity of bacilli

Tumor enlarges through blood vessels

Cancer cells established at secondary sites

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

June 12, 2010

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

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

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.

TPR q shift & record

to know if theres any alteration on vital signs

DAT if not dyspneic

to avoid aspiration

DATE

TIME

DOCTORS ORDER
IVF D5 NM 1L x 12 hours

INTERPRETATION
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. it promotes total expansion of the lung

moderate high back rest

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

>Maximizes available oxygen, especially while ventilation is reduced because of pain.

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.

>Reduces stress and excess stimulation, promoting rest

>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

>Assist with self care needs when indicated and ambulation

>weakness may make ADLs difficult to complete or place patient at risks for injury during activities.

Dependent: >Provide supplemental oxygen as indicated at 12L/min.

>Presence of hypoxemia reduces oxygen available for cellular uptake and contributes to fatigue.

DRUG NAME

ACTION

INDICATION

CONTRAINDICATION

ADVERSE REACTION

NURSING RESPONSIBILI TIES


>Assess cardiorespiratory function: B/P, heart rate and rhythm and breath sounds >Monitor for evidence of allergic reactions and paradoxical bronchospasm

>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.

>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.

DRUG NAME

ACTION

INDICATION

CONTRAINDIC ATION

ADVERSE REACTION

NURSING RESPONSIBILITIES

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 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

>systemic fungal infection: IM injection use in idiophatic thrombocytopeni 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 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.

ADVERSE REACTION Dryness of mouth, throat irritation or cough.

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

ADVERSE REACTION Arrythmias, leukopenia, thrombocytopen ia, myelosuppressi om

NURSING RESPONSIBILITIES >Never give drug IM or SQ

Generic Name: doxorubin HCl Brand Name: Adriamycin Injection: 2mg/ml 20mg/m2 IV once weekly Classification: Antineoplastic s

May interfere with DNAdependent RNA synthesis by intercalation

Bladder, breast, lung, ovarian, stomach and thyroid cancers

>Monitor CBC and hepatic function tests


Monitior ECG every month during therapy Take preventive measures including (adequate hydration) before starting treatment If signs of arrythmias develop, stop drug immediately and notify prescriber

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

Hodgkins disease, malignant effusions (pericardial, peritoneal, pleural)

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 .

>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
>Encourage adequate rest periods between activities

RATIONALE
>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 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!

As ONE! Be it in class or in duty

GROUP 2 so happy together!!!! :))

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