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LUNG ADENOCARCINOMA:A CASE PRESENTATION
A Case StudyPresented to the Faculty ofColegio de DagupanCollege of Nursing
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INTRODUCTION
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
non-smokers, these percentages approach 60 percent in males and 80 percent in females. This is
also more common in Asian populations. Although smoking frequently causes this type of cancer,
secondary risk factors include age, family history, and exposure to secondhand smoke, 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. In this case, doctors perform Chest tube thoracostomy. It is done by placing a hollow plastic
tube between the ribs into the chest to drain fluid, blood, or air from the space around the lungs.
Pleural effusion, the term used to call the excess fluid that had accumulated in the pleural cavity,
which is the fluid-filled space that surrounds the lungs. The excess amount of this fluid affects the
lungs by limiting the expansion of the lungs thus, it impairs breathing.
The group chose Smokey Robinson’s case primarily because they would like to broaden
their knowledge on lung cancer.
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PATIENT’S PROFILEPersonal Data:
Patients Name: Smokey Robinson
Age: 71 years old
Gender: Male
Birth date: March 19, 1939
Address: Don Matias, Burgos, Pangasinan
Nationality: Filipino
Religion [Domination]: Christianity [Roman Catholic]
Civil Status: Married
Educational Attainment: High School Graduate
Occupation: Retired
Weight: 62 kilograms
Clinical/ Admitting Data:
Date of admission: February 9, 2010
Time of admission: 3:30 pm
Hospital: Dagupan Doctors Villaflor Memorial Hospital [021000349O]
Ward [Room & Bed
Numbers]:
303
Attending Physician: Dr. Vivencio Jose P. Villaflor III
Chief complaint: Difficulty breathing
Admitting and Final
Diagnosis:
Left Massive Pleural Effusion secondary to Lung CA
Vital signs on admission:
Temperature:
Pulse Rate:
Respiratory Rate:
Blood pressure:
Surgical Procedure Done:
36ºC Degrees Celsius87 Beats per Minute
23 Cycles per Minute
130/ 90 Millimeters per Mercury
Chest Tube Thoracostomy
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*Pre-operation Diagnosis: Massive left pleural effusion secondary to lung cancer
*Surgeon: Dr. V.V. Villaflor III*Anesthesiologist: Dr. GPV
Source of information: Patient; Patient’s daughter; Patient’s niece
PATIENT’S HISTORY
A. 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 hyperacidity were experienced by the patient in his
lifetime. He did not experience severe, yet common diseases such as dengue and measles. Also, he
has no diabetes mellitus. He has no history of food and drug allergies or hypersensitivities. He
smoked an average of 15 cigarettes per day since high school. Also, he is a social drinker who only
drinks at parties or special events. A notable health condition that he experienced is bronchial
asthma. He coped with asthma by finding a comfortable position during asthma attacks and she did
not take any medications because those were not available yet. His asthma subsided when she was
about 40 years old. A significant disease that he encountered (and is still encountering) later on in
his life is hypertension. He was diagnosed after getting his routine blood pressure checkup. The
doctor advised him to avoid salty and fatty foods and he was also given medicine, specifically
amlodipine besylate(Norvasc).
Medications he took in her lifetime were not numerous, according to him. In fact, he said he
hardly ever took medications. Paracetamol was always his first choice whenever he encounters
fever and colds. He also took some Neozep and mefenamic acid in his lifetime. Also, the patient
noted that he had to comply with taking Norvasc for his hypertension.
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C. Present Health History
The patient’s hypertension is now held at bay by doing follow-up visits to the doctor, asking
for advices and of course, compliance with medications. He also minimized eating his favorite food,
which is pork, for the sake of improving his hypertensive state. He is currently in a pre-
hypertensive state with a blood pressure of 130/90 mmHg. The doctor’s first impression with his
hypertension was that he was in Stage 2, thus we can say that his condition has significantly
improved.
The patient’s lung cancer was diagnosed when he was having an onset of difficulty of
breathing for three days when he was on a vacation in Baguio last May 2009. As the days went by,
he noticed a progression of dyspnea. Initially, he thought that her asthma had recurred, which
prompted him to seek consultation on June 2009. After a series of diagnostic procedures, he 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
of smokers.
On July 2, 2009, upon receiving the chest x-ray result, her physician, Dr. V.V. Villaflor III,
ordered a STAT chest tube thoracostomy. Dr. V.V. Villaflor III performed the procedure with the
help of Dr. GPV as the anesthesiologist.
PHSYICAL ASSESSMENTDate of Assessment: February 11, 2010
Time of Assessment: 8:25 pm
Location of Assessment: Dagupan Doctor’s Villaflor Memorial Hospital
Vital Signs
Temperature : 36 degrees Celsius
Pulse Rate: 87 Beats per Minute
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Respiratory Rate: 23 Cycles per Minute---Rapid
Blood 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 6th and 7th intercostal space of the left lung.
Patient is awake, conscious, coherent, and oriented to time, place, person and reason for admission.
He 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 his general and oral hygiene and was dressed appropriately for the occasion.
Skin
His 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 6th 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.
Head
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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 patient’s 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
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.
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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 patient’s 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
Chest and Lungs
The patient’s thoracic curvature is accentuated, his 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
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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 patient’s 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 patient’s carotid artery produces full pulsations with thrusting
quality.
Breast and Axilla
Patient’s 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 patient’s axillary,
subclavicular and supraclavicular lymph nodes.
Abdomen
Patient’s 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 patient’s 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
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The patient declined to assess his genitals. However, according to the client there were no
discharges and pain during urination.
Back and Extremities
Patient’s peripheral pulses were symmetrical, strong, within normal rate, regular in rhythm
at 24 beats per minute. The patient’s nails took 2 seconds for the capillary refill. The nails were
pinkish in color. Edema was not noted on the patient’s 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 his 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 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 PHYSIOLOGYThe 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 body’s cells, as
you breathe out.
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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
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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 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 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
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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.
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 Value
RationaleResult of Patient
Clinical Significance
Feb 10, 2010
Hemoglobin120– 160 g/dL
The test that measures the amount of hemoglobin per liter of blood
122 g/dL Normal
HematocritM: 42-52%F: 37-47%
The test measures the percentage of RBC in the total blood volume
43% Normal
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 that cause high WBC values include infection, inflammation, damage to body tissues, severe physical or emotional stress (such as a fever, injury, or surgery), burns, kidney failure, lupus, tuberculosis, rheumaoid arthritis, malnutrition, leulemia, and diseases such as cancer.
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Date ExamNormal Value
RationaleResult of Patient
Clinical Significance
Monocyte 2 – 10%
Monocytes have phagocytic action. It removes dead or injured cells, cell fragments, and microorganism. This test is done to diagnose an illness such as inflammatory diseases.
2% Normal
Eosinophils 1 – 8%
Eosinophils initiate allergic responses and act against parasitic infestation. The test is use to diagnose worm infestation.
2% Normal
RBC count4.0-5.0X 10^12/L
The test measures the circulating RBCs in 1 cubic millimeter of blood.
4.73X 10^12/L
Normal
Thrombocytes 150- 300X 10^9/L
The test measures the amount of platelets that are important for blood clotting.
290 X10^9/L
Normal
Lymphocytes 20-40%
The test measures the percentage of the principal component of the body’s immune system.
20% Normal
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PROTHROMBIN TME
Date ExamNormal Value
RationaleResult of Patient
Clinical Significance
Feb 10, 2010 Prothrombin
time12-15 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 seconds
Normal
International Normalized Ratio
0.8–1.2
The test is to know if there is a high chance of bleeding or high chance of blood clot.
0.07 Normal
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DRUG STUDY
Generic Name TheophyllineBrand Name Theocron
Classification Xanthine derivative; Pregnancy risk Category C
Indication and
Dosage
5 mg/kg P.O., then 3 mg/kg q 6 hours for two doses. intenance dosage is 3
mg/kg q 8 hours 250 mg, 1 tab od @ hs
Mode of Action Inhibits Phosphodiesterase, the enzyme that degrades cAMP, resulting in
relaxation of smooth muscle of the bronchial airways and pulmonary blood
vessels.
Contraindication Contraindicated in patients hypersensitive to xanthine compounds (caffeine,
theobromine) and in those with active peptic ulcer or poorly controlled seizure
disorders.
Side/ Adverse
Effects
CNS: restlessness, dizziness, insomnia, seizures, headache, irritability, muscle
twitching.
CV: palpitations, sinus tachycardia, arrhythmias, extrasystoles, flushing, marked
hypotension.
GI: nausea, vomiting, diarrhea, epigastric pain.
Metabolic: urinary catecholamines
Respiratory: respiratory arrest, tachypnea
Nursing
Responsibilities
Dosage may need to be increased in cigarette smokers and in habitual
marijuana smokers because smoking causes drug to be metabolized faster.
Give the drug around the clock, using extended-release product at bedtime.
Monitor vital signs; measure and record fluid intake and output. Expect
improved quality of pulse and respirations.
Patients metabolize xanthenes at different rates; dosage is determined by
monitoring response, tolerance, pulmonary function, and drug level. Drug
levels range from 10 to 20 mcg/ml; toxicity may occur at levels above 20
mcg/ml.
ALERT: evidence of toxicity includes tachycardia, anorexia, nausea,
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vomiting, diarrhea, restlessness, irritability, and headache. If these signs
occur, check drug level and adjust dosage, as indicated.
Look alike-sound alike: don’t confuse extended-release form with regular-
release form. Don’t confuse Theolair with Thyrolar.
Patient Teaching
Supply instructions for home care and dosage schedule.
Warn patient not to dissolve, crush, or chew extended-release products.
Small children unable to swallow these can ingest (without chewing) the
contents of capsules sprinkled over soft food.
Tell patient to relieve GI symptoms by taking oral drug with full glass of
water after meals, although food in stomach delays absorption.
Warn patient to take drug regularly, only as directed. Patients tend to want
to take extra “breathing pills”.
Inform elderly patient that dizziness is common at start of therapy.
Urge patient to tell prescriber about any other drugs taken. OTC drugs or
herbal remedies may contain ephedrine or theophylline salts; excessive
CNS stimulation may result.
Generic Name Multivitamins + minerals Brand Name Centrum®
Classification Vitamins &/or Minerals
Indication and
Dosage
Complete multivitamin & mineral formula.
Dosage: 1 tab/day
Mode of Action
Contraindication 1. If the multivitamin supplement contains fluoride, check with doctor.
Patients should not use it if their drinking water contains more than 0.7
parts per million of fluoride.
2. Contraindicated to patients if allergic to any ingredient in Centrum
3. Inform the doctor or pharmacist if the patient has any medical
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conditions, especially if any of the following applies:
if patient is pregnant, planning to become pregnant, or are
breast-feeding
if patient is taking any prescription or nonprescription medicine,
herbal preparation, or dietary supplement
if patient has anemia, liver problems, or metabolism problems
Side/ Adverse
Effects
No reported adverse effects at doses studied up to approximately 500 mg / day
Nursing
Responsibilities
1. Do not use supplements as a replacement for a diet rich in essential
vitamins and minerals. Encourage the patient to eat the right kind of
food for it contains many important ingredients not available in
supplements.
2. Follow the dosing instructions on the bottle, or use as directed by your
doctor.
3. Do not take more than suggested.
4. If the patient forgot to take the multivitamins for a day, relieve possible
patient concerns by educating them or by resuming his/her regular
schedule the following day.
5. Encourage the patient to store it out of the reach of children, at room
temperature, and keep tightly closed.
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DISCHARGE PLANNING
MEDICATION
Take pain medications as needed
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 these 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 early ambulatory.
Patient will be given deep breathing exercises to promote lung expansion. Use an
incentive spirometer to promote deep breathing.
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.
Advise patients to wash their hands before touching incision sites.
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 visitations to the physician after discharge.
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HEALTH TEACHINGS
The incision area must be kept dry until the wound begins to heal and sponge baths are
recommended for the first day or two.
Provide meticulous chest tube care, and use aseptic technique for changing dressings
around the tube insertion site.
If the patient has open drainage through a rib resection of intercostal tube, use hand
and dressing precautions.
Notify the physician on the following:
o fever and chest colds
o redness, swelling, or bleeding or other drainage from the incision site(s)
o increased pain around the incision site(s)
o abdominal pain, cramping, or swelling
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 the physician if the patient is
uncomfortable
Instruct the client and significant others to report for any unusualities.
Record the amount, color, and consistency of any tube drainage.
The pathology results from patient’s surgery should be available within one week after
your surgery.
Follow-up appointments are generally made before surgery with the physician and a
nurse. The dressing will be changed or removed at patient’s post-operative visit.
DIET
Instruct client may resume his regular diet as soon as he can take fluids after recovering
from anesthesia.
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.