University of Perpetual Help System-DALTA Molino

Prepared by: MAEDINE JOAN S. URBANO

Prepared by: MAEDINE JOAN S. URBANO BSN-4A Page 1

BSN-4A

Prepared by: MAEDINE JOAN S. URBANO BSN-4A

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INTRODUCTION Background Study I have chosen Lung Cancer as my case to be studied since I have personally handled this patient during our clinical duty in Perpetual Help Medical Center in Las Pinas. Since lung cancer is very common disease now a days this case study will help all nursing student to be familiar with the disease, etiology of the disease, common signs and symptoms, complications and proper medical and nursing management needed for this type of diseases. Lung cancer also nown as carcinoma of the lung, is a disease characteri!ed by uncontrolled cell growth in tissues of the lung. If left untreated, this growth can spread beyond the lung by process of metastasis into nearby tissue or other parts of the body. Most cancers that start in the lung, nown as primary lung cancers, are carcinomas that derive from epithelial cells. Etiology Cigarette smoking Cigarette smo ing is the leading cause of lung cancer, accounting for about "#$ of lung cancers. %is for lung cancer increases with the duration, intensity and depth of smo e inhalation. Second&hand 'passive( smo ing also causes lung cancer, but is less strongly associated compared to active smo ing. Cigarettes contain multiple carcinogens 'more than )*( that have been shown to induce cancers in laboratory settings.
+icotine, causes addiction to cigarette smo ing and is also a promoter for

carcinogenesis Carcinogen, nicotine does not initiate carcinogenesis, but it does promote initiated cells by nicotinic cholinergic receptor signalling in the lungs. +icotine has been shown to inhibit apoptosis, proliferate cells, and cause angiogenesis in lung tumours.

Environmental exposure

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 - number of environmental ris factors have been identified, most of which relates

to occupational e.posures such as asbestos, tar, soot, and a number of metals such as arsenic, chromium, and nic el. -ir pollution has also been lin ed to increased ris of lung cancer.

enetics
/here is an increased ris of lung cancer among first&degree relatives, indicating a genetic susceptibility. Candidate gene studies have identified several en!ymes in the cytochrome P& 0#* system as ris factors for lung cancer. 1ne such gene is C2P3-3, which codes for aryl hydrocarbon hydro.ylase. Certain alleles of C2P3-3 are thought to increase the ris of lung cancer through increased metabolic activation of procarcinogens derived from cigarette smo e.

!ain types o" #ung Cancer 3. Small Cell #ung Carcinoma $SC#C%& previously nown as oat cell carcinoma. Small cell lung cancer is a neuroendocrine carcinoma that e.hibits aggressive behavior, rapid growth, early spread to distant sites, e.4uisite sensitivity to chemotherapy and radiation, and fre4uent association with distinct paraneoplastic syndromes

5. Non Small Cell #ung Carcinoma $NSC#C%& is the most common type of lung cancer. It usually grows and spreads more slowly than small cell lung cancer.

T'ree common types o" NSC#C(

)denocarcinomas are often found in an outer area of the lung. S*uamous cell carcinomas are usually found in the center of the lung ne.t to an air tube 'bronchus(.

#arge cell carcinomas can occur in any part of the lung. /hey tend to grow and spread faster than the other two types .

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Signi"icance o" Study /his case study aims to identify and determine the general health problems and needs of the patient with an admitting diagnosis of Lung Cancer. -s a nursing student I can now formulate nursing care plan for the patient that would address this needs effectively. /his would also e4uip nursing students with nowledge, s ills, and attitude to manage patients with same disease. oal -t the end of this nursing case study, as a nursing student I will enhance my understanding on the disease process of Lung Cancer, its nursing management and paves a way to us student&nurses appreciate our roles of being health care providers in the country6s 4uest for health progress and development. Speci"ic O+,ectives( -t the end of this case study, I will be able to, 7efine Lung Cancer 7iscuss and interpret data gathered through theoretical analysis of +ursingHistory, 8ordon6s 33 9unctional Pattern, Physical -ssessment and Laboratory%esults. /race the Pathophysiology of Lung Cancer. Create effective and efficient nursing care plan re4uired by a patient with the above mentioned disease process. 7iscuss the medications ta en by the client, its action, side effects and nursing responsibilities

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-ealt' -istory ). Demograp'ic $ Biograp'ical Data%

Client6s Initial, 8.% 8ender, Male -ge, ## years old %eligion, Catholic :sual Source of Care, Hospital 7ate of -dmission, 9ebruary 3", 5*30 -dmission; Initial 7iagnosis, Lung Cancer 9inal 7iagnosis, C-

B. Source and Relia+ility o" In"ormation

I collected and based my information in the patient6s chart, through interview and laboratory e.aminations.

C. Reason "or Seeking Care or C'ie" Complaints Shortness of breath and easy fatigabilty.

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D. /resent -ealt' -istory Patient is a diagnosed case of +on&small Cell Lung Cancer< s;p C/ , biopsy, right on -ugust 5*3=, s;p -MI on 9ebruary 5**# s;p C->8 ? 0 vessel C-7 on March 5**#. History of present Illness started 3 year P/C year 5*3=, when patient e.perienced persistent cough and intermittent symptoms of fever, shortness of breath and easy fatigability. Moreover, loss of weight was also noted. Patient sought consult wherein wor up was done and patient underwent C/&guide biopsy of left lung on May 5*3=, with histopath said to reveal infection. Patient then too anti&/> medications for = months. Symptoms were noted to be persistent during this time. Patient again sought consult and C/ guided biopsy on the right lung on -ugust 5*3= was done which now revealed malignancy. Patient was advised treatment options such as chemotherapy, radiotherapy and surgery however, patient was lost to follow&up symptoms were still persistent and were later on associated with right&sided chest pain radiating to bac . Patient was also noted to have =&# pillow orthopnea. Severity of symptoms prompted consult at Cagayan de 1ro wherein was advised chemotherapy and radiotherapy hence transfer to Perpetual Help Medical Center for further management. /ast -ealt' -istory or /ast -ealt' Patient 8.% Patient is a diagnosed case of +on&small Cell Lung Cancer< s;p C/ , biopsy, right on -ugust 5*3=, s;p -MI on 9ebruary 5**# s;p C->8 ? 0 vessel C-7 on March 5**#. Patient sought consult wherein wor up was done and patient underwent C/&guide biopsy of left lung on May 5*3=, with histopath said to reveal infection

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0. 0amily -istory Her father has hypertension and her mother has diabetes mellitus. Her grandfather and grandmother on her father side both have hypertension. Her grandfather and grandmother on her mother6s side both have diabetes mellitus

PATERNAL SIDE

MATERNAL SIDE

Unknown

Unknown

Unknown

Unknown

HPN

Lung CA

Lung CA

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LEGENDS: SHADED: DECEASED MALE FEMALE PATIENT

. ORDON1S 22 0UNCTION)# /)TTERN -ealt' /erception&-ealt' !anagement /attern Be"ore -ospitali3ation -ccording to the S1, her husband was e.periencing shortness of breath and easy faitigability, she noticed that her husband used 5&# pillows when lying on bed . During -ospitali3ation -ccording to the S1, she stated that her husband is not in good condition. She believes that doctors, nurses and other medical members will help her mother to recover. S1 also added that they obediently follow all the orders of the doctors.

Nutritional !eta+olic /attern Be"ore -ospitali3ation -ccording to patient he eats = times a day, and doesn6t li e to eat fruits and vegetables. He prefer to drin coffee and smo e cigarettes after every meal. :ntil he lost his appetite. During -ospitali3ation :pon admission, the patient was fed through +8/ . /he diet was 19 53** @cal;day and CA9 B =#*cc C0 banana based plus = scoops of Prosure. Continuous feeding ? 0hours then best for 0 hours. /hen chec for residual.

Elimination /attern

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Be"ore -ospitali3ation -ccording to patient he defecates once a day with semi& formed and brown in color and being eliminated in morning. She voids )&" times a day with yellowish in color.

During -ospitali3ation 7uring our shift, the patient didn6t defecate. He has I9C connected to urine bag with =#* cc and yellow amber in color throughout the shift.

)ctivity Exercise /attern Be"ore -ospitali3ation -ccording to the S1, the patient is sometimes wal ing around their village in Cagayan 7e 1ro but e.perienced of easily shortness of breath and fatigability, so he prefer mostly to used car going to his destination. -bout his hygiene, they see to it that cleanliness must maintain to him. During -ospitali3ation /he patient6s 8CS is 33 'A0, D3c, M)( which is in moderate scale or patient is stuporous. /he S1 is advised to initiate passive range of motion for him to e.ercise.

Sleep&Rest /attern Be"ore -ospitali3ation -ccording to the S1 her husband complains of sleepless night, when shortness of breath attac ed her husband. He uses =&# pillows orthopnea. During -ospitali3ation Patient is in moderate scale of 8CS, but can obeys commands.

Cognitive&/erceptual /attern Be"ore -ospitali3ation -ccording to the S1, her husband can During -ospitali3ation /he patient responds to stimuli by means of

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still recogni!e people most specially his relatives. He can still communicate with people around him through writing because there was an endotracheal& tube attached via mechanical vent. So he was unable to produce sound.

nodding, calling out his name and obeys command.

Sel" perception4Sel" concept Be"ore -ospitali3ation -ccording to the S1, her husband considers himself as a fulfilled man. he was able to raise his child with unconditional love and support to all their needs and now they are all professionals with the help of their family business that was handled by her husband. During -ospitali3ation /he patient6s children are always in the hospital during visiting hours and I personally witnessed how they care and love their mother. /hey want to give the best medical care for him, which only proved how these children love and appreciate their father

Role Relations'ip /attern Be"ore -ospitali3ation -ccording to the S1, he was a loving father and responsible to his children. He provides their needs and sees to it that they are comfortable in their way of life. During -ospitali3ation 7ue to his condition, his children stated that they will do all their best to ta e care of their father. /hey will ma e sure to give bac the care they have received from him.

Coping Stress /attern Be"ore -ospitali3ation Ehen her husband is tired, he drin s During -ospitali3ation 7uring his present condition, he is in a

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alcoholic beverage and smo e cigarettes.

stressful state. His family is there to comfort and give him necessary needs Fust to show their love.

Sexual Reproduction /attern /he patient is not now active in se.ual intercourse because of easily gets tired and shortness of breath attac s. 5alue Belie" /attern He is a %oman Catholic and goes to church when he still can. -. /'ysical )ssessment 0INDIN S Novem+er 678 692: 2694<9 mm-g :<.< C =: +pm 2= cpm Stuporous RE!)R;S Normal )+normal Normal Normal )+normal

B#OOD /RESSURE TE!/ER)TURE /U#SE R)TE RES/IR)TOR> R)TE ENER)# )//RE)R)NCE

-. Revie? o" System @ /'ysical Examination $0e+ruary 2A8 692B% S2S/A M -. 8eneral; 1verall Status %.1.S. Patient is lying on bed, stuporous , but obeys command, GEith +8/ on left nostrils patent continuous feeding for 0 hours I7A-L -wa e Coherent '&( >ody wea ness '&( %estlessn ess -ble to follow command 'H( chest pain on right side that radiate to bac 1beys 1>SA%DA7 Stuporou s SI8+I9IC-+CA 8CS of 33, patient is stuporous a state of mental numbnessas that resulting from stro e, unable to follow commands and manifest body wea ness

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 Eith I9C connected to urine bag draining yellow amber. >. Integu& mentary a.( S in IMaputla ang ulay nya.J as verbali!ed by the S1.

command

Daries from light to deep brown< from ruddy pin to light pin < from yellow overtone s to olive Ehen pinched, s in springs bac to previous state

Pale

d;t decreased tissue perfusion

7ry

d;t decreased activity of sebaceous and sweat glands secondary to aging

d;t prolonged immobility

b.( Hair

ISinusu lay o sya dailyJ verbali!ed by the S1.

c.( +ails

I a agupit o lang ng u o niya.J as verbali!ed by

+o rash Avenly distributed hair /hic hair Sil y, resilient hair +o infection or infestation -ngle of nail plate is 3)*

'H( %ed ulcerations on left arm and sacral Avenly distributed '&( 7andruff +ormal 9indings

'&( +ail clubbing

+ormal 9indings

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the S1.

Highly vascular and pin in light& s inned clients Capillary refill returns within = seconds %ounded normocep halic and symmetri c with frontal, parietal and occipital prominen ces :niform consisten cy< absence of nodules and masses. 5*;5* vision Ayelids& s in intact +o discharg e Ehite sclera Pin ish conFuncti

'&( Cyanotic nail bed

C. Head

Iwala naman a ong n i itanng bu ol sa ulo niyaJ as verbali!ed by the S1.

Capillary refill returns in = seconds %ounded, smooth s ull contour

+ormal 9indings

'&( Scalp lesions upon inspection and palpation 'H( PA%%L +ormal findings

7. Ayes

ILagi syang na api itJ as verbali!ed by the S1.

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A. Aars

IEala namandischa rges sa tenga niyaJ as verbali!ed by the S1.

va /ympani c&pearly gray color, semi transpare nt -uricle aligned with outer canthus of eye Symmetri c +o nasal discharge '&( +asal flaring Pin mucosa Moist oral cavity +o lesion on oral cavity /onsils are not swelling

/ympani c&pearly gray color, semi transpare nt

+ormal findings

9. +ose K Sinuses

Iwala naman, na i itang discharge na lumalabas sa ilong niya.J as verbali!ed by the S1 I7ry ang bibig nya.J as verbali!ed by the S1.

8. Mouth K /hroat

-uricle aligned with outer canthus of eye Symmetri c +o nasal discharge '&( +asal flaring Pin ish mucosa Crac ed lips 1ral sores

+ormal findings

7ry mouth due to decreased salivary production r;t loss of vagal stimulation

H. +ec

IEala naman a ong na i itang bu ol sa leeg nya.J as verbali!ed by the S1.

+o pain during swallowin g Head laterally rotates less than L*o angle +o palpable

'H( /racheost omy

9or Mechanical ventilation access and access for removal of secretion

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 I. %espirat ory IHirap na syang huminga mag isaJ as verbali!ed by the S1.

lymph nodes +ot enlarged %egular and effortless breathing '&( Crac les Produces no sound when breathing %%M50& 0* cpm

>reathing supported by mechanic al ventilator as ordered >:% B rate of 3);min

7ue to Lung carcinoma, the patients need ventilatory assistance Intubation and mechanical ventilation represent a life saving intervention

N. Musculo &s eletal Inaigagalaw naman niya yung paa at amay niya as verbali!ed by the S1. Can move freely +o deformitie s +o swelling at any body parts +o tremors >PM35*;" * mmHg P%M"*& 3=* bpm

%%M3" cpm 'H( muscle wea ness >est motor response in 8CS is #, which means obeys command for movement d;t prolonged immobility

@. Cardio& vascular IEala naman po syang complain na masa itJ as verbali!ed by S1.

>PM35*;L * mmHg P%M"L bpm

+ormal 9indings.

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 L. 8astro& intestinal IHindi na sya ma a ain sa bibigJ as verbali!ed by the S1.

'&( Chest pain +ormal bowel sounds heard every #& 5* sec. 8lobular Soft K non& tender

+8/ on left nostril, 19 continuou s feeding 7iet, the patient was fed through +8/ . /he diet was 19 53** @cal;day and CA9 B =#*cc C0 banana based plus = scoops of Prosure. Continuo us feeding ? 0hours then best for 0 hours. 8CS of 33 'A3 &none, D#& oriented, M)& obeys command (

- person who can6t have very much food at one time needs to be fed continuou sly. Some people are fed day and night. 1thers are fed only during wa ing hours or only at night. Start the feedings at the same hours.

M. +eurolo gic

Inag rerespond nman sya , apag ina ausap siya,through writing as verbali!ed by the S1

'&( Sei!ures '&( Paresthes ia -ble to

d;t neurologic deficit

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follows command

I.

#a+oratory

Electrocardiogram D)TE 5;3";30 RESU#T Sinus tachycardia Left atrial abnormality Poor % wave progression +on&specific S/&/ wave changes NOR!)# R)N E 0.#*&#.#* . 3* O 35;L )N)#>SIS

CT& Scan Date 642<42B Result /here now a large heterogenerously enhancing mass in occupying the upper and mid lung fields. It measures appro.imately 3#.) ? 35.P ? 30.5 cm, )nalysis >ilateral pulmonary masses as described above

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from =.P ? =.# ? =.P cm. some areas hypodensities are seen which may be secondary to areas of necorsis. /his mass compresses on the right side of the trachea and right mainstem bronchus. /he mass compresses the right pulmonary artery< it also displace in anteriorly. /he mass e.tends slightly to the carina. -nother mass is seen in the right upper lobe which now measures #.P ? #.0 ?).3 cm '-P ? /r ? CC( from #.3 ? #.5 ? #.# cm. surrounding interstitial ifiltrates are seen on the left. - small nodular density is also seen in the right middle lobe measuring *.0 ? *.0 cm. 8round glass pattern is seen in the superior segment of the left upper lobe which may be pneumonic in nature. Multiple enlarged lymp nodes are seen in the left paraaortic, aortopulmonary window, carinal and right peribronchial regions with si!es ranging from 3.3 to 5.5 cm. subcentimeter a.illary lyph nodes are seen. Minimal effusion seen in the right hemithora.. Heart is not enlarged< negative for pericardial effusion. /he superior vena cava is slightly compressed. /he aorta

with progression in si!e since *#& 55&3= Minimal pleural effusion, right -theromatous aorta and coronary arteries. Pneumonia , left Multiple mediastinal enlarged lymphadenopath ies. Prominent left adrenal gland.

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is atheromatous. Coronary arteries are calcified. /he left adrenal gland is prominent Sternotomy wires are seen.

-E!)TO#O > D)TE 64 694692B RESU#T %>C& =."# . 3*O35;L NOR!)# R)N E 0.#*&).** . 3*O35;L )N)#>SIS Low %>C d;t chronic anemia probably secondary to HC/& *.== H8>& 33* E>C& 5L.# *.0* Q *.#0L chronic disease d;t low %>C

production 35*.**&3)*.** g;L +ormal 0.#*&3*.** ? 3*OP;L d;t heavy growth of pseudomonas Herginosa Isolated and 'H( lebsiella pneumoniae

Platelet & P3P C'emistry Section D)TE 64 694692B RESU#T >:+& 5.P C%A-& 0)

279&B99 C 29DA4#

NOR!)# R)N E =.5&L.3 mmol;L #"&33* umol;L

)N)#>SIS
lo?er muscle mass caused by a disease, such as muscular dystrophy, or by aging. low potassium (hypokalemia) refers

Potassium& =.*

=.#&#.3 mmol;L

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to a lower than normal level of potassium in bloodstream maybe

d;t nutritional deficiency

Immunology section D)TE 64 2E42B RESU#T Procalcitin level Q *.3* ng;ml NOR!)# R)N E R *.# ng;mL )N)#>SIS
absence of bacteremia in adult patients with acute fever.

Bacteriology D)TE 642=42B RESU#T ramstain& Pus cells& G5#;LP9 Apithelial cells, R5#; LPH 8ram positive cocci, 1CC-SI1+-L 8ram negative Short rods, %are )N)#>SIS ET)

)rterial +lood D)TE 64 6:4692B

as RESU#T pH& L.0L pC*5& 03 P*5&30= HC*=& 5P NOR!)# R)N E L.=#&L.0# =*&0# mmH8 "*&3** mmHg 55&5) mmol;L )N)#>SIS al alosis normal abnormal abnormal

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/)T-O/->SIO#O >
MODIFIABLE -CIGARRETE SMOKING -DRINKS ALCOHOL -RESPIRATORY TRACT INFECTION -ENVIRONMENTAL

NON MODIFIABLE -AGE -GENDER -FAMILY HISTORY

EXPOSURE TO PATHOGENS

INFLAMMATION

BRADYKININ HISTAMIN PROSTAGALNDIN INC! CAPILLARY PERMIALBILITY FLUID " CELLULAR EXUDATION

%S&o'(n)* * o+ ,')-(& %o'(&o.n) -

HYPERSECRETION OF MUCUS PERSISTENT COUGH SINGLE TRANSFORMED EPITHELIAL CELL CARCINOGEN BIND TO CELL#S DNA ABNORMAL CELL GRO$TH DNA CHANGES" ACCUMULATION OF GENTIC CHANGES PULMONARY EPITHELIUM TRASFORMATION INVASIVE CARCINOMA

Non Small Cell #ung Carcinoma

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F. /ro+lem #ist ). )ctual /ro+lem /ro+lem No.

2 6 :

/ro+lem
I/.-0')1 g-* )23&-ng)
Ineffective airway Clearance Imbalanced +utrition

Date Identi"ied 9ebruary 5) , 5*30 9ebruary 5) , 5*30 9ebruary 5) , 5*30

B. /otential /ro+lem
2 6 %is for -spiration %is for Pressure :lcer

9ebruary 5) , 5*30 9ebruary 5) , 5*30

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;. Disc'arge -ealt' Teac'ing /lans

M& A& /&

-dvise the patient to continue the prescribed home medication ordered by the physician. Provide calm and safe environment. Prevent falls and eep your bathroom safe to use. -dvise the patient to avoid fatigue. Instruct to have enough rest at home. Maintain good hygiene by ta ing a bath daily. Chec every day for pressure sores at the heels, an les, nees, hips, tailbone, and elbows. Instruct to continue consulting to a doctor as ordered. Aat healthy foods such as fruits and vegetables. 9ollow low salt, low fat diet and 7M diet. 7rin plenty of water at least "&3* glasses of water a day. -dvise family that patient needs continuous mechanical ventilation set up since patient cannot wean&off mechanical ventilation. -dvise the family members to provide continuous moral support to the patient.

H&

1& 7&

S&

#. Summary o" Client1s Condition as o" #ast Day o" Contact 7ate, 9ebruary 5), 5*30 1n the last day of contact, Patient 8% was received in bed with mechanical ventilation support through endotracheal tube, his vital signs is strictly monitored every 3 hour and with latest D;S as follows, /emp.=L.L C, >P 35*;L*mmHg, %% 3" cpm, H%. P5bpm. Patient inta e and output is also on strict monitoring with total current output of ="* cc. Continuous C>8 monitoring with 35,** pm result of 3LLmg;dl, no insulin provided. +8/ continuous feeding is also provided. Current medications were continued. Patient 8% still stuporous, but can obey commands, 8CS of 33 'A3, D#, M)(.

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