23325558 Case Presentation Final2

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CASEPRESENTATION:

LungAdenocarcinoma

Submitted by:

Mariz Mae S. BoligaoElaine Therese M. Cabacang

Maridee P. Dimagna-ongJulie C. Hubilla

Phea Lenny C. NambatacCarl Stephen B. PerezCharlene Marie A. Raya

BSN-RUBY


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PATIENTS DATA

Personal Data:

Patients Name: Beachin BaratoAge: 65 years oldGender: FemaleBirth date: December 11, 1942Address: Davao CityNationality: FilipinoReligion

[Domination]:

Christianity [Roman Catholic]

Civil Status: Married

EducationalAttainment:

High School Graduate

Occupation: Retired High School Teacher for 10 yearsWeight: 62 kilograms

Clinical/ Admitting Data:

Date of admission: July 2, 2009Time of admission: 9:30 amHospital: Davao Medical School Foundation Davao City

[1604730]Ward [Room & Bed

Numbers]:

H244

Attending Physician: Dr. Allan P. Arreola

Chief complaint: Difficulty breathingAdmitting and Final

Diagnosis:

Left Massive Pleural Effusion secondary to Lung

CAVital signs on

admission:

Temperature:

Pulse Rate:

Respiratory Rate:

Blood pressure:

36C Degrees Celsius

87 Beats per Minute

23 Cycles per Minute

130/ 90 mmHg

Chest Tube Thoracostomy

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Surgical Procedure

Done: *Pre-operation Diagnosis: Massive left pleural effusionsecondary to lungcancer

*Surgeon: Dr. Lei

*Anesthesiologist: Dr. Barinaga

Source of

information:

Patient; Patients daughter-in-law; Husband

FAMILY BACKGROUNDAND HEALTH HISTORY

HEALTH BACKGROUND

A. Family Background

Beachin Barato (not her real name), 65 years old was born in

Misamis Occidental, on December 11, 1942. She spent majority of her

childhood there but was separated with her family during the Philippine-

Japanese war. In fact, she does not know who her real parents and siblings

are. She acquired formal education up to high school while living in an

orphanage. She met her current husband, Mr. Optimus Prime (engineer), who

is from Davao, in Misamis. Optimus Prime was working as an engineer in

Misamis when they met. The couple decided to marry in Davao, where the

family of Optimus Prime can witness the wedding and provide support to the

couple, who are still starting out as a young family.

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The couple has three children, all of which are boys. Their sons got

formal education in Davao City National High School. Moreover, all are

college graduates in different universities and colleges. Mr. Optimus Prime

had a stable job working as an engineer and was their main source of

income. Beachin Barato was a devout Catholic, joining church organizations

and becoming an active member in their mission of enriching their faith,

while recruiting others along the way, as Beachin Barato remarked. This

provided her good experience to be a teacher of Religion in Davao City

National High School for 10 years.

Beachin Barato has nine grandchildren, three for each sons. She only

has two granddaughters. Beachin Baratos sons have become successful in

their chosen professions, thus they had the means to afford good education

for their children. Her eldest son, Bumble Bee, is a manager at a

telecommunications company. He has two sons in college while her youngest

daughter is still in high school. Her second son, Ironhide, is now working in

Pampanga as an engineer for the DPWH. His three sons are still in high

school. The third son, Jetfire is currently working as a manager at an oil

company. He has two sons and a daughter. The eldest is in high school while

the younger children are in grade school.

B. History of Past Illness

The past illnesses that the patient has encountered in the past

were not significant. Only common minor illnesses such as fever, flu, and

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hyperacidity were experienced by the patient in her lifetime. She did not

experience severe, yet common diseases such as dengue and measles. Also,

she has no diabetes mellitus. She has no history of food and drug allergies or

hypersensitivities. She and the entire family, according to her, do not smoke.

Also, consuming alcoholic beverages was something she did not do. A

notable health condition that she experienced is bronchial asthma. She

coped with asthma by finding a comfortable position during asthma attacks

and she did not take any medications because those were not available yet.

Her asthma subsided when she was about 40 years old. A significant disease

that she encountered (and is still encountering) later on in her life is

hypertension. She was diagnosed after getting her routine blood pressure

checkup. The doctor advised her to avoid salty and fatty foods and she was

also given medicine, specifically amlodipine besylate- Norvasc.

Medications she took in her lifetime were not numerous, according to

her. In fact, she said she hardly ever took medications. Paracetamol was

always her first choice whenever she encounters fever and colds. She also

took some Neozep and mefenamic acid in her lifetime. Also, the patient

noted that she had to comply with taking Norvasc for her hypertension.

C. Present Health History

The patients hypertension is now held at bay by doing follow-up visits

to the doctor, asking for advices and of course, compliance with medications.

She also minimized eating her favorite food, which is pork, for the sake of

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improving her hypertensive state. She is currently in a pre-hypertensive

state with a blood pressure of 130/90 mmHg. The doctors first impression

with her hypertension was that she was in Stage 2, thus we can say that her

condition has significantly improved.

The patients lung cancer was diagnosed when she was having an

onset of difficulty of breathing for three days when she was on a vacation in

Pampanga last May 2009. As the days went by, she noticed a progression of

dyspnea. Initially, she thought that her asthma had recurred, which

prompted her to seek consultation on June 2009. After a series of diagnostic

procedures, she was then diagnosed of having lung cancer. The cancer was

classified as adenocarcinoma, or a cancer originating in the mucus producing

glands in the lungs. It is known to be the most common cancer in lifelong

non-smokers.

On July 2, 2009, upon receiving the chest x-ray result, her physician,

Dr. Arreola, ordered a STAT chest tube thoracostomy. Dr. Lei performed the

procedure with the help of Dr. Barinaga as the anesthesiologist.

DEFINITION OF COMPLETEDIAGNOSIS

MASSIVE PLEURAL EFFUSION secondary to LUNG

CANCER

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Pleural effusion, a collection of fluid in the pleural space, is rarely a primary

disease process but is usually secondary to other diseases. Normally, the

pleural space contains a small amount of fluid (5 to 15 ml), which acts as a

lubricant that allows the pleural surfaces to move without friction...

Bronchogenic Carcinoma is the most common malignancy associated with

pleural effusion.

Lung cancer arises from a single transformed epithelial cell in the

tracheobronchial airway. A carcinogen binds to cells DNA and damage it. This

damage results to cellular changes, abnormal cell growth, and eventually a

malignant cell. As damage DNA passed on to the daughter cells, the DNA

undergoes further changes and becomes unstable. With accumulation of

genetic changes, the pulmonary epithelium undergoes malignant

transformation from normal epithelium to eventual invasive carcinoma.

(Kelly, 1997)

Cited on medical-surgical nursing vol. 1 (2000)By: Suzanne C. Smeltzer and Brenda G. Bare

PHSYICAL ASSESSMENT

Date of Assessment: July 4, 2009

Time of Assessment: 5:25 pm

Location of Assessment: Davao Medical School Foundation Hospital

Vital Signs

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Temperature : 36 degrees CelsiusPulse Rate: 87 Beats per MinuteRespiratory

Rate:

23 Cycles per Minute---

RapidBlood Pressure: 130/90 Millimeter per

Mercury

General Survey

During assessment, the patient was eating on bed. There is a chest tube

connected to a chest tube drainage installed on the surgical site located at the 6 th

and 7th intercostal space of the left lung. Patient is awake, conscious, coherent, and

oriented to time, place, person and reason for admission. She is calm and

responsive. The patient has an endomorph type of body; with a height of 158.49

centimeters or 62.4 inches and with a weight of 62 kilograms or 136.4 pounds.

Patient had already done her general and oral hygiene and was dressed

appropriately for the occasion.

Skin

Her skin color is normal, appears thin and translucent, dry and flaky over the

extremities. Skin lost its elasticity and takes longer to return to its natural shape

after being tented between the thumb and finger. The palms and the soles are

calloused. Wrinkles appear on the skin of the face and neck. Freckles are also noted

on the back of the hand. Incision site is 2 cm on the lateral thorax on the 6 th and 7th

intercostal space of the left lung and the compact dressing appears to be fixed. Hair

is black, thin and fine textured but not evenly distributed on the scalp. No infection

or dandruff noted. Scalp is free of lesions. The hair of the eyebrows is coarse. Nails

are pink, firm with capillary refill of 2 seconds and without lesions or clubbing.

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Head

Head is symmetrical, rounded normocephalic with smooth skull contour

positioned at midline and erect with no lumps or ridges. Facial movements are

symmetrical and patient is able to perform different kinds of facial expression

effortlessly and without any obstructions.

Eyes

Patient uses corrective lenses when reading. Eyebrows are symmetrically

aligned and with equal movement with no presence of flakes, scars, or lesions.

Darkened skin around the orbit of the eye is noted. Skin folds of the upper lids are

more prominent, and the lower lids sag. Eyes are dry and lusterless and iris appears

pale with brown discolorations. Conjunctivas of the eye are also pale. Pupil reaction

to light and accommodation is normally symmetrically equal, 2mm in size diameter.

Both eyes are coordinated; move in unison and with parallel alignment.

Ears

The color of patients ears is the same as her facial skin. The left and the

right pinna are symmetrical and are aligned with the inner canthus of the eye.

There is no foul smelling serous or purulent discharges noted. External canal is

normally clear with minimal dry cerumen. The earlobe is elongated and the skin of

the ear is dry and less resilient. Upon palpation, auricles are mobile, and non-

tender; pinna recoils after it is folded. The patient was able to hear normal voice

tones and is able to hear ticking in both ears, as whispered same words on both

ears with correct responses.

Nose

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The nose is symmetric, straight, and uniform in color and no discharges or

flaring noted. Air moves freely as the patient breathes through the nares. Nasal

mucosa is pink, clear and no lesions noted. Nasal septum is intact and in midline.

Upon palpation, no tenderness noted.

Mouth

Lips are dry, cracked and pale in color and with symmetry in contour. Patient

is wearing dentures and has an incomplete set of teeth. Gums are pinkish in color,

dry and firm with yellow discoloration of the enamel and dental carries was noted

on both lower right and lower left of the teeth. The tongue is normally in midline

and was able to move freely, and the base has prominent veins. The patient is able

to swallow with no difficulty.

Pharynx

The patients uvula was located along the midline. The mucosa was pinkish in

color and no lesions or ulcerations noted. The tonsils were pink and smooth, no

discharges or inflammation noted.

Neck

Neck can perform any range of motion without discomfort and with equal

muscle strength as the patient turns his head from left to right; up and down; and

circular motion. Trachea was located centrally in the midline of the neck, spaces are

equal on both sides, and no deviation noted on any part. No lymph nodes noted on

any of the areas of the neck. Thyroid gland is not visible upon inspection. No lymph

nodes palpated

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Chest and Lungs

The patients thoracic curvature is accentuated , her chest was not

symmetrical due to the surgical site and the spine was vertically aligned from the

neck to the buttocks. There was a full and symmetric chest expansion. The

anteroposterior diameter of the chest widens because of barrel-chested

appearance. Upon auscultation, no adventitious sounds can be heard.

Heart

The patients precordial area is flat; there was no lift or heaves. The point of

maximal impulse was located at the fifth left intercostals spaces or along the breast

line in line with the nipples. During palpation, the patients carotid artery produces

full pulsations with thrusting quality.

Breast and Axilla

Patients breasts were even. Skin was smooth and uniform in color with the

abdomen. During palpation, there were no tenderness, masses or nodules noted

with the patients axillary, subclavicular and supraclavicular lymph nodes. There

were also no discharges in the patients nipples. Breast is noted to be saggy in

contour and in shape as a sign of breastfeeding and child birth.

Abdomen

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Patients abdomen is round, with silver white striae, symmetric contour, and

no evidence of enlargement of liver or spleen. Abdominal wall is slacker and

thinner. The patients abdominal girth measures 34 inches or 74.8 centimeters. Skin

returns quickly to its original shape when picked up between two fingers and

released. Growling sounds noted with fifteen (15) bowel sounds per minute. No

areas of tenderness or palpable organs noted upon palpation. Patient defecates

once a day, every morning.

Genitor-Urinary

The patient declined to assess her genitals. However, according to the client

there were no discharges and pain during urination.

Back and Extremities

Patients peripheral pulses were symmetrical, strong, within normal rate,

regular in rhythm at 24 beats per minute. The patients nails took 2 seconds for the

capillary refill. The nails were pinkish in color. Edema was not noted on the patients

upper extremity and lower extremities. There are bilateral warmth on both arms

and legs of the client.

The patient was able to perform range of motion without any discomfort,

swelling, deformity, or nodule on her upper and lower quadrants and on both upper

and lower extremities. Weakness and pain were noted at the upper left extremity of

the patient near the incision or surgical part. There is no missing finger or bone

enlargement on the hands and wrists.

The back is also symmetrical with the spinal cord aligning from the neck

down to the buttocks. There were no deformities or abnormalities on the bone such

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as scoliosis, osteoporosis and alike to be noted. There are also no lesions and the

like noted on the back. Skin color at the back and the extremities are similar with

the rest of the body. Hip joints and thighs can perform range of motion without any

discomfort.

ANATOMY AND PHYSIOLOGY

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.

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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 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.

Lung Cancer

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 1. 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. 2. 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. 3. Bronchioalveolar carcinoma. This is a rare

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subset of adenocarcinoma. It forms near the lungs' air sacs. Recent clinical research

has shown that this type of cancer responds more effectively to the newer targeted

therapies, and 4. Large-cell undifferentiated carcinoma. This cancer forms near the

surface, or outer edges, of the lungs. It can grow rapidly.

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.

Adenocarcinoma

Like other cancers, adenocarcinoma is the growth of abnormal cells. These

cancerous cells multiply out of control and form a tumor. As the tumor grows, it

destroys parts of the lung. Eventually, the tumor's abnormal cells can spread

(metastasize) to other parts of the body, including the local lymph nodes in the

chest and the central portion of the chest, called the mediastinum; the liver; the

bones; the adrenal glands; and other organs, including the brain.

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http://www.lungcancer.org/reading/treatment/types.php#targetedhttp://www.lungcancer.org/reading/treatment/types.php#targetedhttp://www.lungcancer.org/reading/treatment/types.php#targetedhttp://www.lungcancer.org/reading/treatment/types.php#targeted


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When lung cancer metastasizes, the tumor in the lung is called the primary

tumor, and the tumors in other parts of the body are called secondary tumors or

metastatic tumors. Tumors are dangerous because they take oxygen, nutrients, and

space from healthy cells, thus leading to the destruction of the healthy and normal-

functioning cells in our body

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DIAGNOSTIC EXAM

COMPLETE BLOOD COUNT WITH PLATELET COUNT

Date ExamNormal

ValueRationale

Result

of

Patient

Clinical

SignificanceNursing Responsibilities

Hemoglobin 120 160

g/dL

The test that

measures the

amount of

hemoglobin

per liter of

blood

122

g/dL

Normal 1. Discuss and explain the procedure

and purpose of the test.

2. Inform the patient that no fasting is

needed.

3. Assess the patient for any factor that

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Date ExamNormal

ValueRationale

Result

of

Patient

Clinical


July 2,

2009

will probably affect the results of the

test.

4. Make sure patient is well hydrated.

Dehydration elevates the test results.

5. If patient is connected to IVF, make

sure that the blood is not taken from

the arm connected to the IVF.

Hemodilution causes false decrease of

the test results.

6. After the puncture, assess the site

for bleeding or bruising.

Hematocrit M: 42-

52%

F: 37-

47%

The test

measures the

percentage of

RBC in the

total blood

volume

35% Normal

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Date ExamNormal

ValueRationale

Result

of

Patient

Clinical


7. If patient is under treatment from an

infection, inform the patient that the

test will be repeated to monitor

progress.

8. Any abnormality noted will be

reported to the physician.

WBC count 0.5-10

X10^9/L

The test

measures all

leukocytes

present in 1

cubic

millimeter of

blood.

13.6 X

10^9/L

HIGH:

Conditions thatcause high WBCvalues include

infection,inflammation,damage to bodytissues, severephysical oremotional stress(such as a fever,injury, orsurgery), burns,kidney failure,lupus,tuberculosis,rheumaoidarthritis,

malnutrition,leulemia, anddiseases such ascancer.

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Date ExamNormal

ValueRationale

Result

of

Patient

Clinical


Monocyte 2 10% Monocytes

have

phagocytic

action. It

removes dead

or injured

cells, cell

fragments,

and

microorganis

m. This test is

done to

diagnose anillness such as

inflammatory

diseases.

2% Normal

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Date ExamNormal

ValueRationale

Result

of

Patient

Clinical


Eosinophils 1 8%

Eosinophils

initiate

allergic

responses and

act against

parasitic

infestation.

The test is use

to diagnose

worm

infestation.

2% Normal

RBC count 4.0-5.0X

10^12/L

The test

measures the

circulating

RBCs in 1

cubic

millimeter of

blood.

4.73X

10^12/

L

Normal

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Date ExamNormal

ValueRationale

Result

of

Patient

Clinical


Thrombocyt

es

150-

300X

10^9/L

The test

measures the

amount of

platelets that

are important

for blood

clotting.

290

X10^9/

L

Normal

Lymphocyte

s20-40%

The test

meaures the

percentage of

the principal

component of

the bodysimmune

system.

20% Normal

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PROTHROMBIN TME

Date ExamNormal

ValueRationale

Result

of

Patient

Clinical

Significanc

e

Nursing Responsibilities

July 2,

2009

Prothrombi

n time

12-15

seconds

The

prothrombin

time is the

time it takes

plasma to clot

after addition

of tissue

factor. This

measures the

quality of the

extrinsic

pathway (as

well as the

common

pathway) of

coagulation.

12.4

second

s

Normal

1. Discuss and explain theprocedure and purpose of thetest.

2. Assess the patient for anyfactor that will probably affectthe results of the test.

3. Check to see if the patient istaking any medications that mayaffect test results. Thisprecaution is particularlyimportant if the patient is takingwarfarin, because there are anumber of medications that caninteract with warfarin to increaseor decrease the PT time.

4. After the procedure,there mustbe routine care of the areaaround the puncture mark. Applymoist warm compresses on thearea around the puncture mark.

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Date ExamNormal

ValueRationale

Result

of

Patient

Clinical

Significanc

e

Nursing Responsibilities

5.Apply pressure for a fewseconds and the cover the woundwith a bandage.

6. Inform the patient that theremight be mild dizziness and thepossibility of a bruise or swellingin the area where the blood wasdrawn.

International

NormalizedRatio

0.81.2

The test is toknow if there

is a high

chance of

bleeding or

high chance

of blood clot.

0.07 Normal

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DRUG NAME ACTION INDICATION CONTRAINDI-CATION

ADVERSEREACTION

NURSINGRESPONSIBILTIES

DATEORDERED:FEB.13 2011GENERICNAME:NEBULIZATONWITHSALBUTAMOL +IPRATROPIUMQ 8 1 AMP.BRAND NAME:ACTIVENTDOSAGE ANDFREQUENCY:1NEB. 1AMPEVERY 8HOURS.

CLASSIFICATION:SYMPHATOMIMETICS

>STIMULATESBETA2RECEPTORS OFBRONCHIOLESBY INCREASING

THE LEVELS OFCAMP WHICHRELAXESSMOOTHMUSCLES TOPRODUCEBRONCHODILATION.

> RELIEFANDPREVENTIONOFBRONCHOSPASM INPATIENTSWITHREVERSIBLEOBSTRUCTIVE AIRWAYDISEASE ORCOPD>INHALATION AND

TREATMENTOF ACUTEATTACK OFBRONCHOSPASM

>HYPERSENSITIVITY TO ASALBUTAMOL,ALSO TOATROPHINEAND ITSDERIVATIVES.>CARDIACARRHYTHMIAASSOCIATED W/

TACHYCARDIACAUSED BYDIGITALISINTOXICATION.

>FINESKELETALMUSCLE

TREMOR, LEGCRAMPS,PALPITATIONS,

TACHYCARDIA,HYPERTENSION, HEADACHE,NAUSEA,VOMITING,DIZZINESS,HYPERACTIVIT

Y, INSOMNIA,

>ASSESS CARDRESPIRATORYFUNCTION: BHEART RATE ARHYTHM ABREATH SOUND>MONITOR FEVIDENCE ALLERGICREACTIONS APARADOXICALBRONCHOSPASM

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.

DRUG NAME ACTION INDICATION CONTRAINDICATION

ADVERSEREACTION

NURSINGRESPONSIBI-LITIES

Date

Ordered:

Feb.13 2011

Generic

Name:

Dexamethas

one 250 g IV

q8

Brand Name:

Decilone

Dosage and

Frequency:

Classificatio

n:

Hormones

and related

drugs.

>Syntheticglucocorticoidw/ marked

anti-inflammatoryeffect becauseof its ability toinhibitprostaglandinsynthesis,inhibitmigration ofmacrophages,leukocytesandfibroblasts atsites of

inflammation,phagocytosisand lysosomalenzymerelease. It canalso cause thereversal ofincreasedcapillarypermeability.

>Respiratorydiseases

>systemic fungalinfection: IMinjection use in

idiophaticthrombocytopenicpurpura:

>Thromboembolism or fat embolism;thromboplebitis;

necrotizingangiitis; cardiacarrhythmias orECG changes.

>vertigo

> headache

>Impared woundhealing

>visual acuity

>thoat irritation

> Obtain pt.history of underlying

conditionbeforetherapy.

>Assess forpossible druginducedadversereaction.

>Monitorrenal statusand function.

>Assessmental status:

Affect, mood,behavioralchanges.

>Assess ptsand familysknowledge ondrug therapy.

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DRUG NAME ACTION INDICATION CONTRAINDICATION ADVERSEREACTION

NURSINGRESPONSIBI-LITIES

Date Ordered:

Feb. 13, 2011

Generic Name:

Nebulizaton

with

salbutamol +

IPRATROPIUM

q 8 1 amp.

Brand Name:

Atrovent

Classification:

Anticholinergic

s

Chemically relatedto atropine, it

antagonizes theeffect of acetylcholine. Itcauses a local andsite specificbronchodilatationby preventing theincrease inintracellular cyclicguanosine mono-phosphate whichproduced by theinteraction ofacetylcholine w/

the muscarinicreceptors of thebronchial smoothmuscles.

Acuteexacerbations

of chronicobstructivepulmonarydisease(COPD). Usedin conjunctionw/ beta-adrenergicstimulant foracuteasthmaticattacks.

Hyper sensitivity tosoya lecithin or related

food products. Atropineor any anticholinergicderivates.

Dryness ofmouth,

throatirritation orcough.

>Assess patientscondition before

and after drugtherapy. Monitorpeak expiratoryflow.

>Monitor forevidence of allergic reactions,paradoxicbronchopspasm.

>Assess pt andfamilysknowledge ondrug therapy.

>Inform pt. thatdrug is noteffective fortreatment of acutebronchopspasm

>Teach pt. theproper way ofdrugadministration.

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NURSING CARE PLAN

Patients Name: Beachin Barato Age: 65 years old

Chief Complaint: Difficulty of Breathing Attending Physician: Dr. Allan P.Arreola

Gender: Female Shift: 3-11

Diagnosis: Massive pleural effusion secondary to lung cancer. Date: July 2, 2009

Room No.: 4C 444 to 244

DateandTime

Cues Nursing Diagnosis Need(s)

Objective(s) ofcare

Interventions Evaluation

July3,

2009at

5:00pm

Subjectivecues:

Verbalizeddifficulty inbreathing.

Objectivecues:-Rapid

breathing

-Respiratory

rate: 23cycles per

minute- O2

saturationof 65%

Impaired gasexchange related todisease process as

evidenced bydyspnea.

(R) The presence ofpleural fluid (a

complication of lungcancer wherein

pleural fluid collectsin the pleural space

as a result of irritationor obstruction of thevenous drainage by

the tumor), mayhinder adequate lung

expansion, and itcauses the pleural

membranes (essentialfor diffusion of gases)

to compress thus

ACTIVI

TY

EXERCISE

Within 3 hoursof nursing care,the patient will

experienceimproved gasexchanged asevidenced by:

a. Improvedoxygenation (within

88%-100% O2saturation

) andabsence

ofrespiratory distress.

b. Statement of

acceptabl

Independent:

Monitor vital signs.(R)To evaluate

degree ofcompromise.

Assess lung sounds,respiratory rate and

effort and use ofaccessory muscles.(R) Respiratory rate

less than 12 or morethan 24 or use of

accessory musclesindicate distress.Diminished lungsounds indicate

possible poor airmovement andimpaired gas

exchange.

Observe skin and

July 3, 2009 at7:30pm

GOAL PARTIALLYMET.

Within three hoursof nursing care, the

patient statedacceptabledyspnea.

Nakakahinga naako ng mas maayos

kaysa kanina. Inaddition, the

patient participatedin treatment

regimen, such asbreathing exercises.

However, thepatient still has

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affecting gasexchange.

Source:William, L. Hopper, P.

(2007) UnderstandingMedical SurgicalNursing: Third Edition.

Philadelphia: F. ADavis.

edyspnea.

c. Participation in

treatmentregimen(breathin

gexercises)

within thelevel ofability.

mucous membranesfor cyanosis. (R)

Cyanosis indicatespoor oxygenation.

Oral mucousmembrane cyanosis

indicates serioushypoxia.

Monitor for confusion

or changes in mentalstatus. (R) A change

in mental statusindicates impaired

gas exchange.

Elevate head of bedor help the patientlean on over bedtable. (R) Uprightposition helpspromote lung

expansion.

Encourage adequaterest and limit

activities within

clients level oftolerance. Promote a

calm and restfulenvironment. (R)

Helps limit oxygenneeds/consumption.

Dependent:

Monitor for ABG prn.(R) PaO2 < 80

mmHg, PaCO2 >45mmHg or SaO2

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