case presentation lung ca final
TRANSCRIPT
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The general objective of this case study is to
broaden our knowledge about the disease and
to develop skills on how to render the best
possible care to a patient suffering from Lung
CA.
To be able to define Lung CA as well as on
how it is acquired, risk factors, signs and
symptoms.
To be able to know the pathophysiology of
Lung CA.
To be able to know the other problems thatthe client is suffering right now.
To gain more information about patient’s
condition.
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To apply skills learned in the classroom to
actual handling and caring for a patient who
suffered/ is suffering from Lung CA.
To determine the possible nursing
intervention that will be of great help in the
patient’s prognosis. To be able to give the appropriate health
teaching and better understanding of the
disease to the patient, family and significant
others.
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DESCRIPTION OF HEALTH CONDITION
In the year 2000, the Philippines had a total
number of 6,395 reported deaths that was causedby cancer of the lungs, as documented by the
DOH (Philippine Health Statistics 2000, DOH)
Slow-growing lung adenocarcinoma, in actuality,
is the most common kind of lung cancer both insmokers and non-smokers, and in people under
age 45. Adenocarcinoma makes up for about 30
percent of primary lung tumors in male smokers
and 40 percent in female smokers. For non-
smokers, these percentages approach 60 percent
in males and 80 percent in females. This is also
more common in Asian populations.
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Cancer of the lung, like all cancers, results
from an abnormality in the body's basic unit
of life, the cell.Normally, the body maintains a system of
checks and balances on cell growth so
that cells divide to produce new cells only
when needed.
There are two main types of lung cancer,
non-small cell lung cancer and small cell lung
cancer. First is the Non-small Cell LungCancer. NSCLC accounts for about 80%of
lung cancers.
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There are different types of NSCLC, including
•Squamous cell carcinoma(also called
epidermoid carcinoma).This is the most common type of NSCLC. It
forms in the lining of the bronchial tubes
and is the most common type of lung cancer
in men.
• Adenocarcinoma
This cancer is found in the glands of the
lungs that produce mucus. This is the mostcommon type of lung cancer in women and
also among people who have not smoked.
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The second type of lung cancer is theSmall cell Lung Cancer. SCLC accounts for
about 20% of all lung cancers. Although the
cells are small, they multiply quickly and
form large tumors that can spread
throughout the body. Smoking is almost
always the cause of SCLC
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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.
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•Symptoms develop slowly as well. They
include:
•Coughing•shortness of breath
•Wheezing
•chest pain and
•bloody sputum
•Sometimes, this illness may appear at first
to be pneumonia or a collapsed lung.
Sometimes the spread of this cancerproduces large amounts of fluid building up
around the lung.
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Name: Mr. XXX
Address: Brgy. Dila Bay, Laguna
Age: 66 years old
Date of Birth: May 28, 1945
Place of birth: Calauan, Laguna
Religion: Roman CatholicNationality: Filipino
Date of Admission: February 21, 2011
Time: 08:45 am
Admitting Diagnosis: Lung Cancer, Stage II
Case Number: 25112
Admitting Physician: Dr. Giovanni Lagoc, MD
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A. PRESENT HEALTH HISTORY
3 yrs. prior to admission, the client quitted smoking and
there he experienced withdrawal syndrome.8 months prior to admission around June 2010, he felt
difficulty in sleeping, night sweat, chest pain, difficulty in
breathing and productive cough.
7 months prior to admission around July 2010, he was
advised to have chest X-ray and after that he had been
treated with RIPES for 6 months then after 6 months he
complained of feeling bad and that the treatment givenafforded no relief.
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2 months prior to admission around December 2010, he
complained of difficulty swallowing and sleeping
accompanied by severe cough by then they consulted aphysician and after several test he was then diagnosed to
have a Lung cancer, stage 2.
1 month prior to admission around January 2011, he
complained of difficulty urinating and defecating,
hoarseness, numbness in the left upper extremities.
1 day prior to admission at February 20, 2011, he was
admitted due to productive cough, difficulty of breathing,chest pain, weakness, hoarseness, pain in the right neck
and numbness in the left upper extremities.
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B. PAST HEALTH HISTORY
He hadn’t experience any disease when he was a child
even when he turned into teenage life. But when he was at his
adulthood stage of life he was exposed to measles by then he
didn’t have any serious complications until he reaches the age
of 65 where he experienced having severe cough that soonbecame his present condition, lung cancer. One factor was that
he started smoking when he was in grade 6, 1 stick per day and
continued till he used to smoke 1 pack per day. When he
reached the age of 63 he quitted smoking.
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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.
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EXPERIENCE VERBALIZATION INTERPRETATION
Erik Erikson’s
Psychosocial Stages
of Development:
Integrity versus
Despair
“Tanggap ko na
kung anu mang
ipagkaloob ng
maykapal, kunin
man nya ako,handa na ako.”, as
verbalized by the
patient.
INTEGRITY;
As individuals
approach the end of
life, they tend to take
stock of the years
that have gone
before. Our client
feels a sense of
satisfaction with his
accomplishments in
life.
D. DEVELOPMENTAL HISTORY
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Sigmund Freud’s
Psychosexual Stages of
Development:
“Grade 6 ako unang
nanigarilyo, isang stick
kada isang araw
hanggang sa maging
isang kaha na isang
araw.”, as verbalized
by the patient.
ORAL STAGE;
Freud believed that all
human beings pass
through a series of
psychosexual stages;
each stage dominatedby the development of
sensitivity in a
particular erogenous
or pleasure giving
spot in the body.
Furthermore, each
stage poses forindividual a unique
conflict that they must
resolve before they go
to the next higher
stage. If individuals
are unsuccessful inresolving the conflict,
the resulting
frustration becomes
chronic and remains a
central feature of their
psychological make-
up.
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E. SOCIO ECONOMIC
A person who was diagnosed of having a lung
cancer must undergo certain procedures that cost much to
maintain living and prevent further complications. Given
the privilege from raising his children, patient XXX was
being supported financially by her daughter working
abroad as a nurse. He receives ₱10,000.00 monthly for the
examinations and tests he must undergo. His
hospitalization and other needs such as medications,
foods, and etc. are being provided by his other relatives.
Since he and his wife don’t have work, they are seeking for
help in sustaining their daily needs from their children and
other relatives.
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F. PYCHOLOGICAL STATUS
BEFORE THE ILLNESS
Patient XXX was fond of smoking and considers
cigarette as a part of his daily life. He thought that he couldn’t live without a
cigarette in his life and feels that his strength comes from his vice.
Despite the prohibition of his daughter who is a nurse
and his relatives, Patient XXX can’t stop himself from smoking.
WHEN DIAGNOSED / DURING ILLNESS
When patient XXX felt difficulty sleeping, swallowing
and having productive cough, his family consulted a doctor for him. When
advised by the doctor to quit smoking, he thought that he could
successfully cease his smoking habit to relieve feeling of illness. His first
time trying not to smoke made him realize that it is hard to turn his back in
his daily habit and he stated, “Tanggap ko na kung ano mang ipagkaloob
sa akin ng Panginoon” as verbalized by the patient.
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G. SOCIO – CULTURAL
One of patient XXX’s child is a Registered Nurse,
this served as a main factor that influenced his health belief – which is
to seek medical treatment. They first consulted a doctor when he felt ill
and preferred Medical Management for his health. However, they also
believed in “faith healers”, as some of Filipino’s tradition.
H. SPIRITUAL
As Christians, patient XXX and his family was able
to deal with God in their daily lives. When he was diagnosed with Lung
Cancer, the family entrusted patient XXX’s life on God’s hand andprepared themselves in accepting whatever will happen to patient
XXX.
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I. NUTRITIONAL
BEFORE HOSPITALIZATION DURING HOSPITALIZATION
Breakfast
2-3 cups of rice1 med. size fried fish
1 cup coffee
1-2 glasses of water
Breakfast
2-3 tbsp. soup½ glass of water
Lunch
2-3 cups of rice1 ½ servings of vegetable
1 med. size pork
2-3 glasses of water
Lunch
3-4 tbsp. soup½ glass of water
Snack
4-5 pcs. Bread
1 glass of water
Dinner
2-3 cups rice
1 serving of vegetable
2-3 glasses of water
Dinner
2-3 tbsp. soup
½ glass of water
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He ate meals in a moderate
manner- the usual meal for a
sedentary man
When he was diagnosed, the
doctor ordered a soft diet for
him to take.
His usual oral fluid intake was
about 6-7 glasses of water perday, with exception to coffee
and beverages.
At the hospital, Patient XX’s
fluid and electrolytes wasmaintained through
intravenous fluids and
supported by oral fluid intake.
Before the illness, patient XXX
weighs about 65 kilograms.
Previously, patient XXX weighs
about 40 kilograms, due to his
unusual eating habits and
having difficulty swallowing.
J ELIMINATION
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J. ELIMINATION
BEFORE HOSPITALIZATIONDURING HOSPITALIZATION
The patient defecates for at least 1-2
times a day.
January 2011 the patient defecates
twice or thrice a week.
Sometimes the patient defecates
once a day and sometimes none.
February 2011, the patient has
difficulty in voiding, he defecates
twice or thrice a week.
The patient urinates approximately
4-6 times a day with no other
problems in voiding.
During his hospitalization, the
patient has difficulty in urinating. He
uses adult diaper, he consumes 2
diapers per day.
J. ELIMINATION
K. EXERCISE
BEFORE HOSPITALIZATION DURING 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.
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L. HYGIENE
BEFORE
HOSPITALIZATION
DURING
HOSPITALIZATION
He takes a bath 1-2
times a day with Luke
warm water.
His relative provides
sponge bath to him.
He brushes his teeth
every after meal.
He brushes his teeth
irregularly.
He can change and
wear clothes or dress if
ever he wants.
His wife changes his
cloth or any available
relatives.
He can trim nails by his
self.
His relative is the one
who trim his nails.
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L. HYGIENE
M. SLEEP
BEFORE HOSPITALIZATION DURING HOSPITALIZATION
He usually sleeps around
ten o’clock in the evening
and awake at five o’clock
in the morning or earlier.
He had a difficulty in
sleeping due to the attacks
of his condition including
coughing.
He has a productive cough
with clear white sticky
mucous secretions.
The patient sleeps five
hours or less due to
ambiance of hospital.
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AREA METHODS FINDINGS INTERPRETATION
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AREA METHODS FINDINGS INTERPRETATION
Integumenta
ry
Skin
Inspection
- brown
- even in
overall skin
color
- presence ofpaleness of
the skin
-normal, older person’s
skin becomes pale due
to decreased melanin
production and
decreased dermalvascularity.
* Janet Weber, Jane H.
Kelley; Health
Assessment in Nurs ing
3 rd Edi tion © 2007-
Chap ter 11 p. 166
Palpation
- poor skin
turgor
- dry, warm
-older person’s skin
loses its turgor because
of a decrease in
elasticity and collagen
fibers. Also, their skin
may feel dryer becausesebum production
decrease with age.
* Janet Weber, Jane H.
Kelley; Health
Assessment in Nurs ing3 rd Edi tion © 2007-
Hair - black to gray color -normal, gray or white hair
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Inspection
g y
- well distributed in
the scalp and in the
overall skin
, g y
is also result as a person
ages because decrease in
or a lack of melanin
production.
* Rod R. Seeley, Trent
D. Stephens, Philip Tate;Essentials of Anatomy
and Physiology 6th
Edition, International
Edition © 2007- Chapter 5
Integumentary System
p.112
Nails Inspection - pale nail beds - may indicate hypoxia
- clubbing of fingers - results from inflammatory
changes in the bones of
the fingers from prolonged
oxygen deficiency.
* The Respiratory System
Chap ter 12 p. 283 Head
Skull &
Face
Inspection
- symmetrical skull
and is
appropriate in
size
- symmetrical
facial features
- no lumps or
bumps on thescalp
- normal
Eyes & - sclera is white - normal
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Eyes &
Vision
Inspection
- sclera is white
- conjunctiva clear & pinkish in
color
- no blurring of vision
- pupils equally round, reactive to
light and accommodation
(PERRLA)
- normal
- eyes did not converge
- indicates a weakness in
one or more extraocular
muscles or dysfunction of
the cranial nerve that
innervates the particular
muscle.
* Janet Weber, Jane H. Kelley; HealthAssessment in Nurs ing 3 rd Editio n © 2007-
Chapter 13 p. 225
Ears &
Hearing
Inspection
- symmetrical ears and equal in
size
- no build up of cerumen/ear wax
- can hear whispered words at a
distance of 1 ft. in both ears
- normal
Palpation
- no pain reported upon palpation
and no presence of swelling
both ear auricles non tender
- normal
Nose & - nose is symmetrical in shape and same - normal
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Nose &
Sinuses
Inspection
- nose is symmetrical in shape and same
in color with face
- patient can breathe with one nostril and
the other is occluded
- no presence of discharge
- normal
Palpation
- no presence of bumps and tenderness
no pain reported - normal
- non tender sinuses
Mouth
&
Orophar
ynx
Inspection
- no presence of lesions
- pink, moist oral mucosa
- no dentures
- normal
- cough reflex is weaker - because of weakened
respiratory muscles
and decreased ciliary
movement.
- yellowish teeth with some tooth decays,
and missing tooth
- persons who smoke
may have yellow or
brownish teeth
* Janet Weber, Jane H. Kelley;Heal th Assessment in Nurs ing 3 rd
Edition © 2007 - Chapter 15 p. 281
Neck
Neck
muscle
s
Inspection
- symmetrical but weak in strength
- symmetrical movement of neck
muscles
- normal
Lymph
nodes
of theneck
Palpation
lymph nodes are non palpable - normal
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Palpation
- upon deep breathing
anterior thoracic expansion:
approx. 5 cm. ; posterior
thoracic expansion: approx.
6 cm.
- symmetrical expansion
- because of loss of the
accessory musculature in older
persons thoracic expansion
may be decreased although it
should still be symmetrical
* Janet Weber, Jane H. Kelley; Health
Assessment in Nursing 3rd Edition © 2007 -
Chapter 16 p. 313
- increased fremitus in
the upper region of the
lungs
- usually the result of
consolidation or bronchial
obstruction* Janet Weber, Jane H. Kelley; Health
Assessment in Nurs ing 3 rd Edit ion © 2007 -
Chapter 16 p . 312
Percussion
- dullness present - dullness is present when fluidor solid tissue replaces air in
the lung or occupies the pleural
space as in tumor.
Breath sounds
Auscultation
- coarse crackles heard in
the 2nd L and R intercostals
space during early
inspiration to early
expiration
- inhaled air comes into contact
with secretions in the large
bronchi
* Janet Weber, Jane H. Kelley; Health
Assessment in Nursing 3rd Edition © 2007 -
Chapter 16 p. 317
- wheezing heard in the 6th L
and R intercostals space
during expiration
- as air passes through
constricted passages (caused
by swelling, secretions, or
tumor) a high-pitched, musical
sound is produced
* Janet Weber, Jane H. Kelley; Health
Assessment in Nursing 3rd Edition © 2007 -
Chapter 16 p. 317
Cardiovascular & - S1 corresponds with each carotid -
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PeripheralVascular System
Heart(Sounds)
Auscultation
1 p
pulsation. S2 immediately followsafter S1
- no extra heart sounds andmurmurs
Central vessels(carotid arteries
& jugular vein)
Palpation
- equal in pulse rate, rhythm ofcarotid arteries, and amplitude of2+
- normal
- no bruits upon auscultation ofthe carotid arteries
- jugular vein not distended
Peripheral
Vascular
system
(peripheral
pulses, veins,
andperfusion)
Inspection
- uniform in color, presence ofpallor
-Normal
- capillary refill of nail beds is 3
secs.
there is slow capillary
nailbed refill with
respiratory or
cardiovascular diseases
that cause hypoxia
* Janet Weber, Jane H.
Kelley; Health
Assessment in Nursing
3rd Edition - Chapter 11
p. 175
- peripheral pulses (radial, brachial, and
femoral) are equal in pulse rate and
rhythm
- pink coloration returns to palms in 4
secs. if ulnar artery is patent and 3secs.
if radial artery is patent.
-Normal
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- bulging veins - normal findings in an
elderly person
* Janet Weber, Jane H. Kelley; Health
Assessment in Nurs ing 3 rd Edition - Chapter
30 p. 856
Breast & Axillae
Breast size,
symmetry &
contour/shape
Inspection
- breasts are relatively
equal
- normal
Palpation
- no presence ofhardness in any area
Nipples
size, shape,position,
color,
discharge &lesions
Inspection
- nipples at same level
on chest, and of samedark brown color, nopresence of lesions
- normal
Axillary,
subclavicul
ar &
supraclavicular lymphnodes Palpation
- enlarged, hard, non-
mobile left
supraclavicular lymph
node, approximately 2cm. in diameter; no painreported
- the left supraclavicular
lymph node drains the
thorax, abdomen via thoracic
duct. Common causes ofenlargement include
lymphoma, thoracic cancer,
bacterial or fungal infection.* Metastases in Supraclavicular Lymph
Nodes in Lung Cancer : Assessment wi th
Palpation, US, and CT. Radiology 2004;232:
75-80.
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Abdomen:
Abdominal
contour,symmetry
Inspection
- sunken abdomen isobserved
- a scaphoid (sunken)
abdomen may be seenwith severe wieght loss
* Janet Weber, Jane H. Kelley; Health
Assessment in Nurs ing 3 rd Edition ©
2007 - Chapter 20 p. 441
- symmetrical, no presence ofscars, lesions
- normal
- slight pulsation of
abdominal aorta in theepigastric region
- abdominal respiratorymovement is seen
- normal
Palpation
- no palpable mass, nopain reported
- no tenderness and issoft
- lower edge of liver is
palpable and is firm &
even; other organs non
palpable Bowel
sounds
Auscultation
- normal bowel sounds: 5
times/min, heard in all fourquadrants
-Normal
Vascular no bruits over abdominal aorta normal
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Vascularsounds
Inspection
- no bruits over abdominal aorta& femoral arteries
- no friction rubs over area ofliver & spleen
- normal
- tympany is heard overabdomen
- dullness over the liver and
spleen
MusculoskeletalSystem:
Muscle
Inspection
- decreased muscle mass, tone,and strength
- rate of muscle strength is 4 –
active motion against someresistance
- several changes
occur in aging skeletal
muscle that reduce
muscle mass. There is
loss of muscle fiber &
fast-twitch muscle
fibers as aging occurs.
The number of motorneurons also decrease
* Rod R. Seeley, Trent
D. Stephens, Phil ip Tate;
Essentials of Anatomy and
Phys io logy 6th Edi t ion,
International Edition © 2007-
Chapter 7 Muscular System p.194
Bones
Inspection
- no deformities & fractures - normal
- exaggerated thoracic curve - an exaggeratedthoracic curve
(kyphosis) is commonwith aging
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Joints
Inspection
- non tender joints - normal
- bilaterally equal decreased ROMexcept R arm
- the ligament &
tendon surrounding a
joint shorten &
become less flexible
with age, resulting in a
decrease in ROM of
the joints.
* Rod R. Seeley, Trent
D. Stephens, Phil ip Tate;
Essent ia ls of Anatomy and
Phys io logy 6th Edi t ion,
International Edition © 2007-
Chapter 6 Skeletal System p .151
- Non tender joints -normal
Neurologic:
Mentalstatus Inspection
- good grooming, dressesappropriately to weather
- speech is of appropriate ageand flows easily
- maintains eye contact, cansmile & frown appropriately
-normal
Level ofconsciousness Inspection
- awake, alert, and oriented totime, place, person, and
responds to stimuli –
Glascow coma Scale: scoreof 15
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CN IX & X - uvula and soft palate rises bilaterally andsymmetrical upon saying “ah”
fl
- normal
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- gag reflex is present
CN XI - there is symmetric but weak contraction
of the trapezius muscles upon shrugging
of shoulders against resistance
-most of the loss of strength
in an elderly is due to
the loss of muscle
fibers and the loss of
fast-twitch muscle
fibers.* Rod R. Seeley, Trent
D. Stephens, Philip Tate;
Essentials of Anatomy and
Physiology 6th Edition,
International Edition © 2007-
Chapter 7 Muscular System
p.194
CN XII - tongue movement is symmetrical and
smooth and strength is bilateral
- normal
Reflexes
Deep tendon
reflex
Inspection
Biceps reflex - both elbows flexed and contraction of
biceps muscle is felt
- normal
Triceps reflex - both elbows extended, triceps muscles
contracts
Triceps reflex
Patellar reflex
(knee-jerk
reflex)
- knee extends, quadriceps contracts Patellar reflex (knee-
jerk reflex)
Achilles reflex - both foot has plantar flexion Achilles reflex
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Sensoryf ti
- decreased
li h h
- as a result of decreases in the
b f ki ld l
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functions
Inspection
light touchsensation
- correctly
identifies
direction ofmovement of
fingers & toes
with eyes isclosed
number of skin receptors, elderlypeople are less conscious of
something touching or pressingon the skin.
* Rod R. Seeley, Trent
D. Stephens, Phil ip Tate; Essentials of Anatom y and
Physio logy 6th Editio n, Internation al Edition © 2007-
Chapter 8 Nervous System p.237
Genitals/Inguinal:
Inspection
- pubic hair isthin.
- normal findings in an elderlyperson
* Janet Weber, Jane H. Kelley; Health Assessm ent in
Nurs ing 3 rd Editio n - Chapter 30 p. 860-861
Palpation
- penis andtestes sizedecreased
- no swellingand no masses
Rectum/Anus:
Inspection
- anus is darker than
the surroundingskin
- normal findings in an elderly
person * Janet Weber, Jane H. Kelley; Health Assessm ent in
Nurs ing 3 rd Edition - Chapter 30 p. 861
Others:
Senses
Inspection
- numbness in his
neck, left shoulderand arm,
- there is compression of the leftsubclavian artery & brachial plexus
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Oncologists talk about stages of lung cancer
based on something called the TNM system. In
this system, T refers to the size of the tumor, N
refers to the involvement of any lymph nodes
and where they are located, and M indicates ifthere are any metastases, that is spread of the
tumor to other regions of the body.
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Using the TNM system, stage 2 lung cancer is
described as:
2A – T1N1M0 – Meaning the tumor is less than 3cm (1 ½ inches) in size, and it has spread to
nearby lymph nodes.
2B – T2N1M0 – The tumor is greater than 3 cm issize and has spread to local lymph nodes, or
T3N0M0 – The tumor is any size and has not
spread to lymph nodes, but is located in theairway or has spread to local areas such as the
chest wall or diaphragm.
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ANATOMY
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The lungs are a pair of cone-shaped breathingorgans in the chest. The lungs bring oxygen into
the body as you breathe in. They release carbon
dioxide, a waste product of the body’s cells, as
you breathe out.
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Each lung has sections called lobes.
The left lung has two lobes, while the
right lung is slightly larger and hasthree lobes.
Two tubes called bronchi, lead from
the trachea (windpipe) to the rightand left lungs. These bronchi are
sometimes also involved in lung
cancer disease process.
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Tiny air sacs called alveoli and small
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Tiny air sacs called alveoli and small
tubes called bronchioles make up the
inside of the lungs.
A thin membrane called the pleura
covers the outside of each lung and
lines the inside wall of the chestcavity. This creates a sac called the
pleural cavity.
The pleural cavity normally contains asmall amount of fluid that helps
the lungs move smoothly in the
chest when you breathe.
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Mechanism of Breathing
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PREDISPOSING FACTORS-Gender
PRECIPITATING FACTORS-Smoking History: 53 pack-yrs. of
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Age: 65 y/o
g y y
smoking
Passage of Cigarette Smoke
to lower respiratory system
Nicotine Tars Carbon Monoxide
Goblet
CellsMucocilliary Clearance
System Impairement
Ineffective Cough
Reflex
Impaired Alveolar
Macrophages
Ability to
Phagocytize
inhaled
Foreign
Particles
Chronic irritation and exposure
of epithelial tissue to smoking
↑ Vulnerability of epithelial tissue toirritants and carcinogens
Interruption of Normal cells
Activation of normal cancer cell
Primary growth of tumor in theepithelial tissue
- Desquamation of cells
-Hypersecretion of mucus
-Hyperplasia of the basal cells
-Metaplasia of normal
Respiratory epithelium
Exposure / inhalation of
infected aerosol through droplet
Inhaled nuclei lodge in alveoli
Binding of bacterial cell wall to
macrophage
Spread of bacilli via lymphatic
system to upper lobes of the
lungs
Tubercle bacilli replicates
slowly due to sensitivity to heat
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Failure of the immune system torecognize cancer cell as foreign
body
Patient stopped for smoking 2
years ago (2008)
Progression and proliferation of
cancer cellsProgression of tubercle bacilli
Increased tumor size Formation of granuloma
Obstruction of the
bronchus due to
tumor
Cancer cell
detached from
primary tumor
Tumor enlarges
through blood
vessels
Migrate via lymph
nodes or blood
circulation
Cancer cells
established at
secondary sites
FNAB Dec. 23, 2010
Non small cells lungcancer
Positive for
Adenocarcinoma
Drainage of necrotic material
into the tracheobronchial tree
Scar formation
Full blown immunity of bacilli
Active infection of Bacilli-hemoptysis
-productive cough
-chest pain and tightness
-night sweating
(May 2010)
May 22, 2010
X-ray shows Koch’s infection
at right upper lobe
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January 2011
-hoarseness
-dysphagia-Non- productive cough
-anorexia
-weight loss
February13, 2011
-hoarseness
-dysphagia-Non- productive cough
-numbness of the Left neck, shoulder & arm
-dyspnea-wheezes on 6th intercostal space
-crackles on trachea & 2nd intercostals space
-palpable lymph node on left neck
May 2010Started anti-tubercular drugs
for six months (May-Nov.
2010)
Recurring of symptoms after 6
months of treatment
Dec. 13, 2010
•Pulmonary masslingular segment, with
mediastinal and LeftHilar lymphadenopathy,
biopsy is suggested•PTB of undetermined
activity, Right upper lobe
Dec. 23, 2010Unchanged right upper lobe
PTB and left hilar mass
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J 12 2010
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Ju ne 12, 2010
RADIOLOGIC FINDINGS
IMPRESSION:
•Minimal Koch’s infection, Right upper lobe.
•Interstitial pneumonitis Right hemothorax.
•Consolidation pneumonia Lingular zone.
•Please correlated clinically.
November 2, 2010
RADIOLOGIC FINDINGS
IMPRESSION:
•Follow up study since June 12, 2010 shows progression of the
confluent opacities in the Left peri hilar area and Left lower
lobe. Note of slight interval clearing of the Right upper lobe
infiltrated. No other interval changes seen.
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December 23 2010
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December 23, 2010
RADIOLOGIC FINDINGS
IMPRESSION:
•Resolving Pneumonia, Left Hilum.
•Unchanged right upper lobe PTB and left Hilar
mass.
•Mild cardiomegaly.•Atherosclerotic thoracic aorta.
•Degenerative osseous changes.
December 23, 2010
FNABIMPRESSION:
•Positive for malignant cells.
•Non small cell compatible with adenocarcinoma.
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DATE TIME DOCTOR’S ORDER INTERPRETATION
2/ 21/11 8:45 am admit To monitor the
condition of the
patient and for
implementation of
proper treatment.
secure consent It protects the
client’s right to
self-
determination.
To inform the
client on what
treatment or
procedure he/she
might be involved.
TPR q shift &record
to know if there’sany alteration on
vital signs
DAT if not
dyspneic
to avoid
aspiration
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DATE TIME DOCTOR’S ORDER INTERPRETATION
IVF D5 NM 1L x 12
hours
for replacement of fluid and
electrolyte loss
O2 at 1-2 L/min via
nasal cannula
Decreases shortness of breath.
Nasal Cannula delivers a
relatively low concentration of
oxygen which is 24% to 45% at
flow rates of 2 to 6 liters per
minute.
moderate high back
rest
it promotes total expansion of the
lung
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DATE TIME DOCTOR’S ORDER INTERPRETATION
Nebulizaton with
salbutamol +
ipratropium q 8 1 amp.
salbutamol relieves nasal
congestion and reversible
bronchospasm by relaxing
the smooth muscles of the
bronchioles.
ipratropium relieve any
reversible airways blockage
associated with problems
such as repeated infections
affecting the airways.
refer For further studies of the
disease and for more
improved medical
management.
Meds:
Dexamethasone 250 g
IV q8
Dexamethasone reduces the
swelling, itching, and
redness that can occur in
these types of conditions.
This medication is a mild
corticosteroid.
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TREATMENT
Surgery: Surgical removal of the tumor is
generally performed for limited-stage (stage I or
sometimes stage II) NSCLC and is the treatmentof choice for cancer that has not spread beyond
the lung. About 10%-35% of lung cancers can be
removed surgically, but removal does not always
result in a cure, since the tumors may alreadyhave spread and can recur at a later time.
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The surgical procedure chosen depends upon the size
and location of the tumor. Surgeons must open the chest
wall and may perform a wedge resection of the lung
(removal of a portion of one lobe), a lobectomy (removal
of one lobe), or a pneumonectomy (removal of an entire
lung). Sometimes lymph nodes in the region of the lungs
also are removed (lymphadenectomy). Surgery for lung
cancer is a major surgical procedure that requires generalanesthesia, hospitalization, and follow-up care for weeks
to months. Following the surgical procedure, patients
may experience difficulty breathing, shortness of breath,
pain, and weakness. The risks of surgery includecomplications due to bleeding, infection, and
complications of general anesthesia.
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Radiation: Radiation therapy may be employed as a
treatment for both NSCLC and SCLC. Radiation therapy
uses high-energy X-rays or other types of radiation to kill
dividing cancer cells. Radiation therapy may be given as
curative therapy, palliative therapy (using lower doses of
radiation than with curative therapy), or as adjuvant
therapy in combination with surgery or chemotherapy.
The radiation is either delivered externally, by using amachine that directs radiation toward the cancer, or
internally through placement of radioactive substances in
sealed containers within the area of the body where the
tumor is localized. Brachytherapy is a term used todescribe the use of a small pellet of radioactive material
placed directly into the cancer or into the airway next to
the cancer. This is usually done through a bronchoscope.
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Radiation therapy does not carry the risks of major
surgery, but it can have unpleasant side effects, including
fatigue and lack of energy. A reduced white blood cell
count (rendering a person more susceptible to infection)
and low blood platelet levels (making blood clotting more
difficult and resulting in excessive bleeding) also can
occur with radiation therapy. If the digestive organs are in
the field exposed to radiation, patients mayexperience nausea, vomiting, or diarrhea. Radiation
therapy can irritate the skin in the area that is treated,
but this irritation generally improves with time after
treatment has ended.
Chemotherapy: Both NSCLC and SCLC may be treated
ith h th Ch th f t th
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with chemotherapy. Chemotherapy refers to the
administration of drugs that stop the growth of cancer
cells by killing them or preventing them from dividing.
Chemotherapy may be given alone, as an adjuvant tosurgical therapy, or in combination with radiotherapy.
While a number of chemotherapeutic drugs have been
developed, the class of drugs known as the platinum-
based drugs have been the most effective in treatment of
lung cancers.
Chemotherapy is the treatment of choice for most SCLC,
since these tumors are generally widespread in the body
when they are diagnosed. Only half of people who have
SCLC survive for four months without chemotherapy.With chemotherapy, their survival time is increased up to
four- to fivefold. Chemotherapy alone is not particularly
effective in treating NSCLC, but when NSCLC has
metastasized, it can prolong survival in many cases.
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Chemotherapy may be given as pills, as an intravenous
infusion, or as a combination of the two. Chemotherapy
treatments usually are given in an outpatient setting. A
combination of drugs is given in a series of treatments,
called cycles, over a period of weeks to months, with
breaks in between cycles. Unfortunately, the drugs usedin chemotherapy also kill normally dividing cells in the
body, resulting in unpleasant side effects. Damage to
blood cells can result in increased susceptibility to
infections and difficulties with blood clotting (bleeding orbruising easily).
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Other side effects include fatigue, weight loss, hair
loss, nausea, vomiting, diarrhea, and mouth sores. The
side effects of chemotherapy vary according to the
dosage and combination of drugs used and may also vary
from individual to individual. Medications have been
developed that can treat or prevent many of the sideeffects of chemotherapy. The side effects generally
disappear during the recovery phase of the treatment or
after its completion.
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Assessment Diagnosis Planning Interventions Rationale Evaluation
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S> “Naninikip
and dibdib ko”
as verbalized by
the patient
O> with
productive
cough
With mucous
secretions:
• scant in
amount
•Clear , thickwhitish sputum
>use
sternocleidomas
toid muscles
and scaline
muscles while
breathing
>with clubbingof fingers in both
hands.
> RR= 12bpm
Impaired gas
exchange
related to
altered
oxygen
supply as
evidenced
by clubbing
of fingers
GOAL:
Adequate gas
exchange
DESIRED
OUTCOMES
After the
nursing
interventions,
the patient will
be able to :
a. Demonstr
ateimproved
ventilation
and
adequate
oxygenatio
n.
b. Participate
intreatment
regimen
with in
level of
ability or
situation
INDEPENDENT
>Note
respiratory rate,
depth and ease
of respiration.
>Observe for the
use of accessory
muscle, pursed
lip breathing,
changes in skin
or mucous
membrane color.
>Maintain patent
airway
>Reposition
frequently,
placing patient in
sitting positions
and supine to
side positions.
>Respiration may be
increase as a result of
pain or as an initial
compensatory
mechanism to
accommodate for loss
of lung tissue.
Increased work of
breathing and
cyanosis may indicate
increasing oxygen
consumption andenergy expenditures
and reduced
respiratory reserve
>Airway obstruction
impedes ventilation,
impairing gas
exchange.
>maximize lung
expansion and
drainage of
secretions.
After series
of nursing
intervention
the patient
was able todemonstrate
improve
ventilation
and
adequate
oxygenation.
Assessment Diagnosis Planning Interventions Rationale Evaluation
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>encourage
or assist with
deep
breathing
exercises
and pursed
lift breathing
as
appropriate
DEPENDEN
T
>Administer
supplemental
oxygen via
nasal cannula,
partial
rebreathing
mask, or high
humidity face
mask as
indicated.
Oxygen
saturation: 1-2 L/min
>promote
maximal
ventilation
and
oxygenation
and reduces
or prevent
atelectasis
>Maximizesavailable
oxygen,
especially
while
ventilation is
reduced
because of
pain.
Assessment
Diagnosis
Planning Interventions Rationale Evaluation
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S>”Nahihirapan
akong
huminga” as
verbalized by
the patient
O > with
productive
cough
>with mucous
secretions
o Scant in
amount
and
o Clear,thick,
whitish
sputum
>with crackles
breath sounds
heard on the
second
intercoastal
spaces
>with wheezing
on the sixth
intercoastal
space heard
upon expiration
Ineffective
airway
clearance
related to
constriction
of the airway
as evidenced
by
decreased
respiratory
rate:12bpm
and deep
shallow
breathing.
GOAL:
Effective airway
clearance
Desired Outcome:
After nursing
intervention
patient will be
able to:
a. Demonstrat
e patent
airway
b. Expectorate
secretions
c. Clear breath
sounds
d. Decrease
use of
accessory
muscles for
breathing
e. Demonstrat
e behavior
to improveor maintain
clear
airways
Independent:
>Auscultate chest
for character of
breath sounds and
presence of
secretions
>Observe amount
and character of
sputum secretions.
Investigate
changes as
indicated
>encourage oral
intake if not
contraindicated and
within cardiac
tolerance.
Dependent:
>Administer
bronchodilators,
expectorants and/
or analgesics as
indicated
>noisy respiration,
ronchi, and wheezes
are indicative of
retained secretions
and/or airway
obstruction
>presence of thick and
tenacious bloody or
purulent sputum
suggest development of
secondary problems
>adequate hydration
aids in keeping
secretions loose or
enhance expectorations
>relieves
bronchospasms to
improve airflow.
Expectorants increases
mucous production andliquefy and reduce
viscosity of secretions,
facilitating removal.
Alleviation or chest
discomfort promotes
cooperation and
breathing exercises and
enhances effectiveness
of respiratory therapies.
After series of
nursing
interventions,
patient will
demonstrate
patent airway,
will have
expectorated
secretions and
decrease use
of accessory
muscles while
breathing.
Assessment Diagnosis Planning Intervention
s
Rationale Evaluation
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s
S>” Hindi na ako
makagawa ng
datirati kong
ginagawa dito sa
bahay” as
verbalized by the
patient.
O>decreased
physical activity
> easy fatigability
>body malaise
>RR; 12bpm
>decrease depth
of breathing
>poor muscle
tone
Activity
intolerance
related to
imbalance
between oxygen
Supply anddemand as
evidence by
decreased physical
activity & easy
fatigability
Goal:
Enhance activity
tolerance
Desired Outcome:
After nursing
interventions,
patient will be
able to:
a. Participate
in
techniques
to enhance
activity
tolerance
b. Eliminate
and reduce
factors that
contribute
activity
tolerance
c. Demonstrat
e adecrease in
physiologica
l signs of
intolerance
Independent:
>evaluate client’s
response to
activities.
>Note reports of
dyspnea, increased
weakness or
fatigue, and
changes in vital
signs during and
after activities.
>Encourage use of
stressmanagement and
diversional
activities as
appropriate.
>Assist and
encourage to
assume
comfortableposition for rest
and sleep.
>Establishes
client’s capabilities
or needs and
facilitates choice
of intervention
>Symptoms may
be result of/or
contribute to
intolerance of
activity
>Reduces stress
and excess
stimulation,
promoting rest
>Patient may be
comfortable with
head of bed
elevated, sleepingin chair or leaning
forward on
overbed table with
pillows support.
After nursing
intervention
patient will be able
to:
Participate in
techniques toenhance activity
tolerance
Eliminate and
reduce factors that
contribute activity
intolerance
Demonstrate a
decrease in
psychological signs
or intolerance.
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Assessment Diagnosis Planning Intervention
s
Rationale Evaluation
>Encourageadequate fluid
intake
>Assist with self
care needs when
indicated and
ambulation
Dependent:
>Provide
supplemental
oxygen asindicated at 1-
2L/min.
>Preventsdehydration
(which increases
fatigue)
>weakness may
make ADLs
difficult to
complete orplace patient at
risks for injury
during activities.
>Presence of
hypoxemia
reduces oxygen
available forcellular uptake
and contributes
to fatigue.
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DRUG NAME ACTION INDICATION
CONTRAINDI-CATION
ADVERSEREACTION
NURSING
RESPONSIBILITIES
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Date Ordered:
Feb.21 2011
Generic Name:
Nebulizaton
with
SALBUTAMOL
+ ipratropium q
8 1 amp.
Brand Name:
Activent
Dosage and
Frequency:
1Neb. 1amp
every 8 hours.
Classification:
Symphatomim
etics
>Stimulates
Beta2 receptors
of bronchioles
by increasing
the levels of
cAMP which
relaxes smooth
muscles to
produce
bronchodilation.
> Relief and
prevention of
bronchospasm
in patients withreversible
obstructive
airway disease
or COPD
>Inhalation
and treatment
of acute attackof
bronchospasm
>Hypersensitivit
y to a
salbutamol, also
to atrophine and
its derivatives.
>Cardiac
arrhythmia
associated w/
tachycardia
caused by
digitalis
intoxication.
>Fine skeletal
muscle tremor,
leg cramps,
palpitations,
tachycardia,
hypertension,
headache,
nausea,
vomiting,
dizziness,
hyperactivity,
insomnia,
>Assess cardio-
respiratory
function: B/P,
heart rate and
rhythm and
breath sounds
>Monitor for
evidence of
allergic
reactions and
paradoxical
bronchospasm
DRUG NAME ACTION INDICATION
CONTRAINDI-CATION
ADVERSEREACTION
NURSINGRESPONSIBI-
LITIES
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Date Ordered:
Feb.21 2011
Generic Name:
Tramadol
Brand Name:
Dolotral
Dosage and
Frequency:
Classification:
Analgesics,
Muscle
Relaxants and
Uricosurics
Corticosteriods
.
>Centrally
acting analgesic
not chemically
related to
opioids butbinds to mu-
opioid receptors
and inhibits
reuptake of
norepinephrine
and serotonin.
>Tramadol is
used for
moderate to
severe pain.
>Hypersensitivit
y
>Acute
intoxication with
alcohol,hypnotics,
centrally acting
analgesics,
opioids, or
psychotropic
agents.
>Vasodilation:
Dizziness/vertig
o, headache,
somnolence,
stimulation,anxiety,
confusion,
coordination
disturbance,
sleep disorders,
seizures.
>Pruritus,
sweating, rash.
>Visual
disturbances,
dry mouth.
>Nausea,
diarrhea,
constipation,
vomiting,dyspepsia,
abdominal pain,
anorexia,
flatulence.
>Assess patient’s
pain (location,
type, character)
before therapy
and regularlythereafter to
monitor drug
effectiveness.
>Assess for
hypersensitivity
reactions:pruritus,
rash and urticaria.
>Monitor for
possible drug
induced adverse
reactions: CNS:
stimulation,
dizziness, vertigo,
headache,
somnolence,
anxiety,
confusion,coordination
disturbance,
malaise,
euphoria,
nervousness,
sleep disorder,
seizures.
DRUG NAME ACTION INDICATION CONTRAINDIC
ATION
ADVERSE
REACTION
NURSINGRESPONSIBI-
LITIES
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Date Ordered:
Feb.21 2011
Generic Name:
Dexamethason
e 250 g IV q8
Brand Name:
Decilone
Dosage and
Frequency:
Classification:
Hormones and
related drugs.
>Synthetic
glucocorticoid w/
marked anti-
inflammatory
effect because of
its ability to inhibit
prostaglandin
synthesis, inhibit
migration of
macrophages,
leukocytes and
fibroblasts at sites
of inflammation,phagocytosis and
lysosomal
enzyme release.
It can also cause
the reversal of
increased
capillary
permeability.
>Respiratory
diseases
>systemic
fungal infection:
IM injection use
in idiophaticthrombocytopeni
c purpura:
>Thromboembol
ism or fat
embolism;
thromboplebitis;necrotizing
angiitis; cardiac
arrhythmias or
ECG changes.
>vertigo
> headache
>Impared
wound healing
>visual acuity
>thoat irritation
> Obtain pt.
history of
underlying
condition beforetherapy.
>Assess for
possible drug
induced adverse
reaction.
>Monitor renal
status and
function.
>Assess mental
status: Affect,
mood,
behavioral
changes.
>Assess pt’s
and family’s
knowledge on
drug therapy.
DRUG NAME ACTION INDICATION CONTRAINDIC
ATION
ADVERSE
REACTION
NURSINGRESPONSIBI-
LITIES
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Date Ordered:
Feb. 21, 2011
Generic Name:
Nebulizaton
with
salbutamol +
IPRATROPIUM
q 8 1 amp.
Brand Name:
Atrovent
Classification:
Anticholinergic
s
Chemically
related to
atropine, it
antagonizes the
effect ofacetylcholine. It
causes a local
and site specific
bronchodilatatio
n by preventing
the increase in
intracellular
cyclic guanosine
mono-
phosphate
which produced
by the
interaction of
acetylcholine w/
the muscarinicreceptors of the
bronchial
smooth
muscles.
Acute
exacerbations of
chronic
obstructive
pulmonarydisease
(COPD). Used
in conjunction
w/ beta-
adrenergic
stimulant for
acute asthmatic
attacks.
Hyper sensitivity
to soya lecithin
or related food
products.
Atropine or anyanticholinergic
derivates.
Dryness of
mouth, throat
irritation or
cough.
>Assess
patient’s
condition before
and after drug
therapy. Monitorpeak expiratory
flow.
>Monitor for
evidence of
allergic
reactions,
paradoxic
bronchopspasm
.
>Assess pt’ and
family’s
knowledge on
drug therapy.
>Inform pt. that
drug is noteffective for
treatment of
acute
bronchopspasm
>Teach pt. the
proper way of
drug
administration.
DRUG NAME ACTION INDICATION CONTRAINDIC
ATION
ADVERSE
REACTION
NURSINGRESPONSIBI-
LITIES
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Generic Name:
doxorubin HCl
Brand Name:
Adriamycin
Injection:
2mg/ml
20mg/m2 IV
once weekly
Classification:
Antineoplastic
s
May interfere
with DNA-
dependent RNA
synthesis by
intercalation
Bladder, breast,
lung, ovarian,
stomach and
thyroid cancers
Patients with hx
of sensitivity
reactions to
drug or its
components
Patients with
marked
myelosuppressi
on induced by
previous
treatment withother antitumor
drugs or therapy
Arrythmias,
leukopenia,
thrombocytopen
ia,
myelosuppressi
om
>Never give
drug IM or SQ
>Monitor CBC
and hepatic
function tests
Monitior ECG
every month
during therapy
Takepreventive
measures
including
(adequate
hydration)
before starting
treatment
If signs of
arrythmias
develop, stop
drug
immediately and
notify prescriber
DRUG NAME ACTION INDICATION CONTRAINDIC
ATION
ADVERSE
REACTION
NURSINGRESPONSIBI-
LITIES
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Generic Name:
mechlorethami
ne Hcl
Brand Name:
Mustargen
Injection: 10mg
vials
o.4 mg/kg
intracavitarily
Classification:
Antineoplastic
s
Cross-links
strands of
cellular DNA
and interferes
with RNA
transcription,cau
sing an
imbalance of
growth that
leads to cell
death.
Hodgkin’s
disease,
malignant
effusions
(pericardial,
peritoneal,
pleural)
Patients
hypersensitive
to drug and
those with
infectious
diseases
Patients with
severe anemia
or depressed
neutrophil and
PLT count
Patient who
underwent
radiation
therapy or
chemotherapy
nausea,
vomiting,
snorexia,
diarrhea,
leukopenia, mild
anemia
thrombocytopen
ia,
agranulocytosis
>Dilute using up
to 100 ml saline
for injection
>Turn pt side to
side every 5 to
10 mins. To
distribute drug
To prevent
bleeding, avoid
all IM injectionswhen PLT count
is less than 50,
000/mm3
Monitor pt
closely for bone
marrow
suppression
Give BT for
cumulative
anemia
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ACTION RATIONALE
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ACTION RATIONALE
>Assess respiratory rate and depth >useful in evaluating the degree of
respiratory distress and /or chronicity of
the disease process .
>Auscultate chest , noting presence
or characteristic of breath sounds,
presence of secretions.
>to identify etiology or precipitating
factors
>Observe characteristics of cough >cough can be persistent but
ineffective, especially if client is elderly,
acutely ill, or debilitated.
>Perform physical and or
psychological assessment
>to determine the extent of the
limitation of the current condition.
ACTION RATIONALE
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ACTION RATIONALE
>Encourage adequate rest periods
between activities
>to limit fatigue
>Establish a minimum weight goal
and daily nutritional requirements
>provides comparative baseline for
effectiveness of therapy
>Give frequent oral care, remove
expectorated secretions promptly,
provide specific container for disposal
of secretions and tissue
>noxious tastes, smell and sight are
prime deterrents to appetite and can
produce nausea and vomiting with
increase respiratory difficulty
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MEDICATION Inform client to take medications on
time, or as directed for the full course of
therapy, even if feeling better. Inform theclient about the possible side effects of
the medication.
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EXERCISE
Encourage ambulation.Patient will be given deep breathing
exercises to promote lung
expansion. Use an incentive spirometerto promote deep breathing
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EXERCISE
Encourage ambulation.Patient will be given deep breathing
exercises to promote lung
expansion. Use an incentive spirometerto promote deep breathing
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TREATMENT
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•Instruct the client to continue drug therapy as
ordered.
•Inform the client as well as the family the dangers ofnon compliance to treatment regimen.
•Discuss to the client the complication of the
condition.
•Inform client to do exercises and stretches.•Instruct the patient to report to the physician
promptly about any changes on health condition.
•Encourage patient to strictly comply with the doctor’s
orders, especially in taking prescribed medications
•Encourage the patient to have followed up visitationsto the physician after discharge
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OUTPATIENT
•Remind client on the arrangements to be made with
the physician for follow-up check ups
•Follow-up check up regularly in order to monitor
and properly manage patient’s illness.
•Continue medication as ordered.
•Instruct to have a follow-up check-up or refer to thephysician if the patient is uncomfortable
•Instruct the client and significant others to report for
any unusualities
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This case study has provided us with importantinformation about the patient’s lung cancer
disease condition and its nursing care
interventions prior to the treatments and
medical procedures done with the patient.
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“Challenges make us more
responsible. Always remember that,
life without struggles is a life without
success. Don’t give up. Learn to rest,
but NEVER QUIT future RN’s! ”
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As ONE! Be it in
class or in duty
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GROUP 2… so happy
together!!!! :))
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