I.

PERSONAL DATA Name: Address: Sex: Age: Date of Birth: Place of Birth: Civil Status: Religion: Educational Attainment: Occupation: Name of Hospital: Chief Complaint: Admitting Diagnosis: Attending Physician: Angelito Samonte Viray Brgy. Magrafil Gonzaga, Cagayan Male 64 Years old December 13, 1946 Brgy. Magrafil Gonzaga, Cagayan Married Roman Catholic Elementary Undergraduate-Grade 5 Farmer Alfonso Ponce Enrile Memorial District Hospital DOB accompanied with Chest pain and Non-productive Cough Massive Pleural Effusion 2o Large Cell Carcinoma Stage III Ofelia dela Cruz Datu, MD and Emely Pumaras, MD

Date & Time of Admission: July 18, 2011 @ 2:43 PM

II. DISCUSSION OF THE CASE LUNG CANCER Definition Lung cancer is the leading cause of cancer deaths in the United States, among both men and women. It claims more lives each year than colon, prostate, lymph and breast cancers combined. Yet most lung cancer deaths could be prevented. That's because smoking accounts for nearly 90 percent of lung cancer cases. Your risk of lung cancer increases with the length of time and number of cigarettes you smoke. If you quit smoking, even after smoking for many years, you can significantly reduce your chances of developing lung cancer. Protecting yourself from other risk factors for lung cancer, such as exposure to asbestos, radon and secondhand smoke, also decreases your risk. Symptoms Lung cancer typically doesn't cause signs and symptoms in its earliest stages. Signs and symptoms of lung cancer typically occur only when the disease is advanced. Signs and symptoms of lung cancer may include: > A new cough that doesn't go away > Changes in a chronic cough or "smoker's cough" > Coughing up blood, even a small amount > Shortness of breath > Chest pain > Wheezing > Hoarseness Causes Lung cancer most commonly begins in the cells that line the lungs. Smoking causes the majority of lung cancers both in smokers and in people exposed to secondhand smoke. But lung cancer also occurs in people who never smoked. In these cases, there may be no clear cause of lung cancer. Doctors have identified factors that may increase the risk. How smoking causes lung cancer Doctors believe smoking causes lung cancer by damaging the cells that line the lungs. When you inhale cigarette smoke, which is full of cancer-causing substances (carcinogens), changes in the lung tissue begin almost immediately. At first your body may be able to repair this damage. But with each repeated exposure, normal cells that line your lungs are increasingly damaged. Over time, the damage causes cells to act abnormally and eventually cancer may develop. The lungs are full of blood vessels and lymph vessels, giving lung cancer cells easy access to travel to other parts of the body. For this reason, lung cancer may spread to other parts of the body before one experiences any signs or symptoms. In many cases, lung cancer may spread before it can even be detected in the lungs.

Types of lung cancer Doctors divide lung cancer into two major types based on the appearance of lung cancer cells under the microscope. The doctor makes treatment decisions based on which major type of lung cancer one has. The two general types of lung cancer include: > Small cell lung cancer. Small cell lung cancer, sometimes called oat cell carcinoma, occurs almost exclusively in heavy smokers and is less common than non-small cell lung cancer. > Non-small cell lung cancer. Non-small cell lung cancer is an umbrella term for several types of lung cancers that behave in a similar way. Non-small cell lung cancers include squamous cell carcinoma, adenocarcinoma and large cell carcinoma. Risk factors A number of factors may increase the risk of lung cancer. Some risk factors can be controlled, for instance, by quitting smoking. And other factors can't be controlled, such as your sex. Risk factors for lung cancer include: > Smoking. Smoking remains the greatest risk factor for lung cancer. The risk of lung cancer increases with the number of cigarettes one smokes each day and the number of years they have smoked. Quitting at any age can significantly lower the risk of developing lung cancer. > Your sex. Current or former women smokers have a greater risk of lung cancer than do men who have smoked an equal amount. Though it isn't known why, some experts speculate that women have a greater susceptibility to the cancer-causing substances found in tobacco. Others believe that estrogen may play a role. Women also are known to inhale more than men do, and they are less likely to quit. > Exposure to secondhand smoke. Even if one does not smoke, the risk of lung cancer increases if one is exposed to secondhand smoke. > Exposure to radon gas. Radon is produced by the natural breakdown of uranium in soil, rock and water that eventually becomes part of the air you breathe. Although unsafe levels of radon can accumulate in any building, the greatest exposure risk most people face is at home. Radon testing can determine whether levels are safe.

> Exposure to asbestos and other chemicals. Workplace exposure to asbestos and other substances known to cause cancer such as arsenic, chromium,nickel and tar soot also can increase the risk of developing lung cancer, especially if one is a smoker. > Family history of lung cancer. People with a parent, sibling or other first- degree relative with lung cancer have an increased risk of the disease. > Excessive alcohol use. Drinking more than a moderate amount of alcohol no more than one drink a day for women or two drinks a day for men may increase your risk of lung cancer. Tests and diagnosis Screening Doctors aren't sure whether one should undergo screening for lung cancer. Even if one has an increased risk of lung cancer for instance, if one is a smoker it isn't clear that a chest X-ray or computerized tomography (CT) scan can be beneficial. Some studies show that these tests can find cancer earlier, when it may be treated more successfully. But other studies find that these tests often reveal more benign conditions that require invasive testing and expose people to unnecessary risks. Screening for lung cancer is controversial among doctors. Studies are ongoing to determine what types of tests may be helpful and who would benefit from lung cancer screening. Diagnosis > Imaging tests. An X-ray image of the lungs may reveal an abnormal mass or nodule. A CT scan can reveal small lesions in the lungs. > Sputum cytology. If one has a cough and are producing sputum, looking at the sputum under the microscope can sometimes reveal the presence of lung cancer cells. Before the test, the patient may be asked to breathe a mildly irritating mist to help produce more sputum. > Tissue samples (biopsy). A sample of abnormal cells may be removed in a procedure called a biopsy in order to diagnose lung cancer. A doctor can perform a biopsy in a number of ways, including bronchoscopy, in which the doctor examines abnormal areas of the lungs using a lighted tube that is passed down the throat and into the lungs; mediastinoscopy, in which an incision is made at the base of the neck and surgical tools are inserted behind the breastbone to take tissue samples; and needle biopsy, in which the doctor uses X-ray or CT images to guide a needle through the chest and into a suspicious lump or nodule to collect cells. A biopsy sample may also be taken from lymph nodes or other areas where cancer has spread, such as the liver. Staging Once lung cancer has been diagnosed, the doctor will work to determine the extent, or stage, of cancer. The cancer's stage helps the doctor decide what treatment is most appropriate. Staging tests may include imaging procedures that allow the doctor to look for signs that cancer has spread beyond the lungs, such as magnetic resonance imaging (MRI), positron emission testing (PET) and bone scans.

Stages of non-small cell lung cancer Stage I. Cancer at this stage has invaded the underlying lung tissue but hasn't spread to the lymph nodes. Stage II. This stage cancer has spread to neighboring lymph nodes or invaded the chest wall. Stage IIIA. At this stage, cancer has spread from the lung to lymph nodes in the center of the chest. Stage IIIB. The cancer has spread locally to areas such as the heart, blood vessels, trachea and esophagus all within the chest or to lymph nodes in the area of the collarbone or to the tissue that surrounds the lungs within the rib cage (pleura). Stage IV. The cancer has spread to other parts of the body, such as the liver, bones or brain. Stages of small cell lung cancer Limited. Cancer is confined to one lung and to its neighboring lymph nodes. Extensive. Cancer has spread beyond one lung and nearby lymph nodes, and may have invaded both lungs, more remote lymph nodes or other organs. Complications Fluid in the chest (pleural effusion). Lung cancer can cause fluid to accumulate in the space that surrounds the lungs in the chest cavity (pleural space). Pleural effusion can result from cancer spreading outside the lungs or in reaction to lung cancer inside the lungs. Fluid accumulating in the chest can cause shortness of breath. Treatments are available to drain the fluid from your chest and reduce the risk that pleural effusion will occur again. Cancer that spreads to the pleura is considered inoperable, so surgery isn't an option for treatment. Cancer that spreads to other parts of the body (metastasis). Lung cancer often spreads (metastasizes) to other parts of the body most commonly the opposite lung, brain, bones, liver and adrenal glands. Cancer that spreads can cause signs and symptoms, including pain, nausea, headaches or others basedon what organ is affected. In some cases, treatments are available for isolated metastasis, but in most cases, the goal of treatment for metastasis is only to relieve signs and symptoms. Death. Unfortunately, survival rates haven't improved for people diagnosed with lung cancer. In most cases, the disease is fatal. Almost 60 percent, or three out of every five people, diagnosed with lung cancer die within a year. This number includes people diagnosed with all types of lung cancer at all stages of the disease. People diagnosed at the earliest stages have the greatest chances for a cure. Treatments and drugs Cancer treatment regimen is based on a number of factors, such as overall health, the type and stage of cancer, and own preferences. Treatment options typically include one or more treatments, including surgery, chemotherapy, radiation therapy or targeted drug therapy. In some cases patients may choose not to undergo treatment. For instance, the patient may feel that the side effects of treatment will outweigh the potential benefits. If that is the case, the doctor may suggest comfort (palliative) care to treat only the symptoms the cancer is causing, such as pain.

Surgery During surgery your surgeon works to remove the lung cancer and a margin of healthy tissue. Procedures to remove lung cancer include: Wedge resection to remove a small section of lung that contains the tumor along with a margin of healthy tissue Lobectomy to remove the entire lobe of one lung Pneumonectomy to remove an entire lung Lung cancer surgery carries risks, including bleeding and infection. The lung tissue will expand over time and make it easier to breathe. One may also feel pain in the muscles of the chest and in the arm on the side where the patient had the operation. The doctor may recommend physical therapy or a rehabilitation program to help restore the strength and range of motion. Chemotherapy Chemotherapy uses drugs to kill cancer cells. One or more chemotherapy drugs may be administered through a vein in the arm (intravenously) or taken orally. A combination of drugs usually is given in a series of treatments over a period of weeks or months, with breaks in between so that the body can recover. Chemotherapy can be used as a first line treatment for lung cancer or as additional treatment after surgery. In some cases, chemotherapy can be used to lessen side effects of the cancer. Radiation therapy Radiation therapy uses high-powered energy beams, such as X-rays, to kill cancer cells. Radiation therapy can be directed at the lung cancer from outside the body (external beam radiation) or it can be put inside needles, seeds or catheters and placed inside the body near the cancer (brachytherapy). Radiation therapy can be used alone or along Sometimes it's administered at the same time as also be used to lessen side effects of lung cancer. Targeted drug therapy > Bevacizumab (Avastin). Bevacizumab stops a tumor from creating a new blood supply. Blood vessels that connect to tumors can supply oxygen and nutrients to the tumor, allowing it to grow. Bevacizumab is usually used in combination with chemotherapy and is approved for advanced and recurrent non-small cell lung cancer. Bevacizumab carries a risk of severe bleeding. > Erlotinib (Tarceva). Erlotinib blocks chemicals that signal the cancer cells to grow and divide. Erlotinib is approved for people with advanced and recurrent non-small cell lung cancer that haven't been helped by chemotherapy. Erlotinib side effects include a skin rash and diarrhea. with other lung cancer treatments. chemotherapy. Radiation therapy can

Prevention > Don't smoke. If you've never smoked, don't start. Talk to your children about not smoking, so they can understand how to avoid this major risk factor for lung cancer. Many current smokers began smoking in their teens. Begin conversations about the dangers of smoking with your children early, so they know how to react to peer pressure. > Stop smoking. Stop smoking now. Quitting reduces your risk of lung cancer, even if you've smoked for years. Talk to your doctor about strategies and stopsmoking aids that can help you quit. Options include nicotine replacement products, medications and support groups. > Avoid secondhand smoke. If you live or work with a smoker, urge him or her to quit. At the very least, ask him or her to smoke outside. Avoid areas where people smoke, such as bars and restaurants, and seek out smoke-free options. > Test your home for radon. Have the radon levels in your home checked, especially if you live in an area where radon is known to be a problem. High radon levels can be remedied to make your home safer. > Avoid carcinogens at work. Take precautions to protect yourself from exposure to toxic chemicals at work, if you're given a face mask for protection, always wear it. > Eat a diet full of fruits and vegetables. Choose a healthy diet with a variety of fruits and vegetables. Food sources of vitamins and nutrients are best. Avoid taking large doses of vitamins in pill form, as there may be unknown harms. For instance, researchers hoping to reduce the risk of lung cancer in heavy smokers gave them beta carotene supplements. Results showed the supplements actually increased the risk of cancer in smokers. > Drink alcohol in moderation, if at all. Limit yourself to one drink a day if you're a woman or two drinks a day if you're a man. Anyone age 65 and older should drink no more than one drink a day. > Exercise. Aim to achieve at least 30 minutes of exercise on most days of the week. Check with your doctor first if you aren't already exercising regularly. Start out slowly and continue adding more activity. Biking, swimming and walking are good choices. Add exercise throughout your day park farther away from work and walk the rest of the way or take the stairs rather than the elevator.

LARGE CELL CARCINOMA AN OVERVIEW

Large cell carcinoma is a form of non-small cell lung cancer. Non-small cell lung cancers account for 80% of lung cancers, and of these, roughly 10% are large cell carcinomas of the lung. Large Cell Carcinoma Overview Large cell carcinomas are also called large cell lung cancers. They are named for the appearance of large round cells when examined under the microscope, although the tumors themselves tend to be large as well when diagnosed. Large cell carcinomas often occur in the outer regions of the lungs, and tend to grow rapidly and spread more quickly than some other forms of non-small cell lung cancer. Large Cell Carcinoma Symptoms Because large cell carcinomas often begin in the outer parts of the lungs, well-known symptoms of lung cancer, such as a chronic cough and coughing up blood, may be less common until later in the

disease. Early symptoms of large cell carcinomas that may be overlooked may include fatigue, mild shortness of breath, or achiness in your back, shoulder, or chest. Since large cell carcinomas are often found in the outer regions of the lungs, they can cause fluid to develop in the space between the tissues that line the lung (pleural effusions), and invade the chest wall. This can cause pain in your chest or side that worsens with a deep breath. Large cell carcinomas can also secrete hormone-like substances that cause symptoms referred to as paraneoplastic syndrome. In men, these substances may cause enlargement of the breasts, something known as gynecomastia. Large Cell Carcinoma Diagnosis Large cell carcinoma of the lungs is often first suspected when abnormalities are seen in an X-ray. Further evaluation may include: y y y Chest CT Scan Bronchoscopy PET Scan - a test designed to look for actively growing tumors

Depending upon the results, the doctor will usually want to obtain a sample of tissue to confirm the diagnosis, and will order further tests to check to see if your cancer has spread. Large Cell Carcinoma Stages Large cell carcinoma is broken down into 4 stages: y Stage 1 The cancer is localized within the lung and has not spread to any lymph nodes. y Stage 2 The cancer has spread to lymph nodes or the lining of the lungs, or is in a certain area of the main bronchus. y Stage 3 The cancer has spread to tissue near the lungs. y Stage 4 The cancer has spread (metastasized) to another part of the body Lung Cell Carcinoma Causes Large cell carcinomas of the lungs are more strongly associated with smoking than some other types of non-small cell lung cancers, but other causes can contribute as well: y Environmental Causes of Lung Cancer y Occupational Causes of Lung Cancer y Genetics and Lung Cancer Large Cell Carcinoma Treatments Depending upon the stage, treatment for large cell carcinomas of the lung may include surgery, chemotherapy, radiation therapy, or a combination of these. Many clinical trials are in progress looking for new ways to treat lung cancer, and to help decide which treatments are most effective. y Surgery When large cell carcinomas are caught in the early stages, surgery may offer a chance for a cure. Chemotherapy Chemotherapy may be used alone, in conjunction with radiation therapy, or following surgery for lung cancer. Examples of chemotherapy medications used with large cell carcinomas include Altima (pemetrexed) and Platinol (cisplatin).

Targeted Therapies Targeted therapies are medications that are designed to attack cancer specifically. Because they work by targeting proteins on cancer cells, or normal cells that have been hijacked by a tumor in its attempt to grow, they may have fewer side effects than traditional chemotherapy. Examples of targeted therapies that may be used includeTarceva (erlotinib) and Iressa (gefitinib). Radiation Therapy Radiation therapy may be used to treat lung cancer or to control symptoms related to the spread of cancer.

Large Cell Carcinoma Prognosis The 5-year survival rate for lung cancer overall is sadly only about 15%. For those diagnosed in the early stages of the disease, the prognosis is much better. One variant of large cell carcinoma, large cell neuroendocrine carcinoma, has a poorer prognosis than large cell carcinoma. III. GORDONS FUNCTIONAL ASSESSMENT A. Health Perception/Health Management Pattern When asked whether or not Mr. Viray feels that he is healthy, he expressed a negative answer. He perceives a healthy person as someone who is strong enough to do some chores without feeling fatigued. He expressed that he does not really follow a healthy pattern since before he had cancer, he wakes up already looking for a cigarette and that he can consume almost 2 packs of Marlboro a day. When asked if he religiously goes to the hospital for check-up since he has cough which according to him started months ago and was never relieved, he said that his house is a long way travel to the hospital so he might as well save the money for his family instead of spending it for check-ups. B. Nutritional-Metabolic Pattern Mr. Viray relays that he is not picky when it comes to food. He eats whatever his wife prepares for their family since he conveys that they do not have much to choose from. Sometimes, Mr. Viray eats just twice a day because of budgetary constraint. When he was assessed, his skin was noticeably dry, his teeth were obviously stained and his estimate weight was 60 kgs. C. Elimination Pattern During the day of the interview, Mr. Viray did not pass his stool but he said that normally, he defecates at most twice a day. On that day, he urinated thrice but he specified that normally, he urinates four times a day depending on his water intake. He said that his bowel consistency is usually smooth and greenish brown in color. D. Activity-Exercise The patient relates that he does not do regular exercises. His own way of exercising is through walking and doing some activities in the fields since he is a farmer. However, he said that he is not quite tolerant enough for strenuous activities since he experiences easy fatigability and that when he does some heavy work even light ones, he experiences difficulty of breathing and chest pain. E. Cognitive-Perceptual When Mr. Viray was physically assessed, he was able to read a writing a meter away from him but he was not able to read a sign posted on the door of the hospital room approximately 6 meters away from him. When he was shown a face pain scale, he stated that sometimes, when he experiences chest pain, he feels that the pain can be leveled up to number 5 which is the most painful. When he

experiences chest pain, he usually drinks mefenamic acid 500 mg. if he tolerates it. But if not, he is rushed to APEMDH. Mr. Viray, though 64 years old, he does not have problems remembering important dates and events. He is coherent and conversant during the interview. F. Sleep-Rest Pattern Since his severe coughing started, Mr. Viray stated that he was not able to attain a complete sleep at night. Usually, He only sleeps 3 hours then wakes up because he experiences difficulty of breathing or sometimes chest pain. In their house, he sleeps in a banig with his wife and three children. He uses a pillow and a blanket to sleep on. G. Self-Perception/Self Concept When Mr. Viray was asked on what he thinks about his condition, he stated, in a low-voice tone implicating a bit of a disappointment that he already accepts his health status and that he is ready for whatever may happen to him. Only he was sorry of his loved ones that he may be leaving. H. Role Relationship Since Mr. Viray is the breadwinner in the family, he thinks of his responsibilities as heavy and that he is afraid of what may happen to his family if he would die from his disease. When he was asked how his relationship with his wife and children is, he said that even if they do not have much, they go along very well. I. Sexuality-Reproductive The patient was a bit hesitant when asked whether or not he is still active when it comes to his sexual functioning. However, he stated that his last sexual contact with his wife was last year but he could not remember the exact date. Although he wanted to have sexual contact this year, he controls his urges because he thinks that he is not already capable of having sex, it might trigger his chest pain. J. Coping-Stress Tolerance Before he was diagnosed with cancer, when under stress, usually with work, he said that he usually takes a rest while he smokes. Everytime that he has a problem, whether it is family or work, he smokes. That is one way of alleviating his stress. Also, when he is being angered by his children, he releases the tension by scolding them. K. Value-Belief Mr. Viray was born a Roman Catholic but he said that his last visit to the church was years ago. He does not read the bible but he believes in God and that life is just borrowed from God dying is Gods plan.

IV. ANATOMY AND PHYSIOLOGY HUMAN RESPIRATORY SYSTEM .

Overview Cells in the body require oxygen to survive. Vital functions of the body are carried out as the body is continuously supplied with oxygen. Without the respiratory system exchange of gases in the alveoli will not be made possible and systemic distribution of oxygen will not be made possible. The transportation of oxygen in the different parts of the body is accomplished by the blood of the cardiovascular system. However, it is the respiratory system that carries in oxygen to the body and transports oxygen from the tissue cells to the blood. Thus, cardiovascular system and respiratory system works hand in hand with each other. A problem in the cardiovascular system would affect the other and vice versa. Functional Anatomy of the Respiratory System Nose The nose is the only external part of the respiratory system and is the part where the air passes through. During inhalation and exhalation, air enters the nose by passing through the external nares or nostrils. Nasal cavity is found inside the nose and is divided by a nasal septum. The receptors for the sense of smell, olfactory receptors are found in the mucosa of the slit-like superior part of the nasal cavity which is located beneath the ethmoid bone. Respiratory mucosa lines the rest of the nasal cavity and rests on a rich network of thin-walled veins that warms the air passing by. Important information about nose is the presence of the sticky mucus that is produced by the mucosas gland. This important characteristic moistens the air and traps the incoming bacteria and other foreign debris passing through the nasal cavity. Cells of the nasal mucosa are ciliated and it creates a gentle current that moves the contaminated mucus posteriorly towards the throat, where it is swallowed and digested by stomach juices. In cases where the temperature of the environment is cold, the cilia become sluggish. Thus, more mucus are allowed to accumulate in the nasal cavity and to dribble outward through the nostrils. This is the main reason why a runny nose is noted during a cold day.

Conchae these are three mucosa-covered projections or lobes that greatly increase the surface area of the mucosa exposed to the air. Aside from that, conchae increase the air turbulence in the nasal cavity. Palate a partition that separates the nasal cavity from the oral cavity. Anteriorly, the palate that is supported by a bone called the hard palate and the one which is unsupported is the soft palate. Paranasal Sinuses these are structures surrounding the casal cavity and are located in the frontal, sphenoid, ethmoid and maxillary bones. Pharynx The pharynx is a 13 cm long muscular tube that is commonly called the throat. This muscular passageway serves as a common food and air pathway. This structure is continuous with the nasal cavity anteriorly via the internal nares. Parts of pharynx: 1. Nasopharynx the superior portion of the pharynx. The pharyngotympanic tubes that drain the middle ear open in this area. This is the main reason why children who have otitis media may follow a sore throat or other tyoes of pharyngeal infections since the two mucosae of these regions are continuous. 2. Oropharynx middle part 3. Laryngopharynx part of pharynx that enters the larynx. When food enters the oral cavity, it travels to the oropharynx and laryngopharynx. However, instead of entering the larynx, the food is directed into the esophagus and not to the larynx. Tonsils clusters of lymphatic tissues found in the pharynx. Types of Tonsils: 1. Palatine tonsils tonsils found at the end of the soft palate. 2. Pharyngeal tonsils lymphatic tissues located high in the nasopharynx. This is also called adenoid. 3. Lingual tonsils located at the base of the tongue. Larynx The larynx is the one that routes the air and food into their proper channels. Also termed as the voice box, it plays an important role in speech. This structure is located inferior to the pharynx and is formed by: 1. Eight rigid hyaline cartilages 2. Spoon-shaped flap of elastic cartilage, which is called the epiglottis. Thyroid cartilage this is the largest hyaline cartilage that protrudes anteriorly in males and is referred to as the Adams apple. Epiglottis this is a flap of tissue that serves as a guardian of the airways as it protects the superior portion of the larynx. The epiglottis does not restrict passage of air into the lower respiratory passages when a person is not swallowing. However, when a person swallows food, the epiglottis tips and forms a lid or blocks the opening of the larynx so that food will not be directed to the lower respiratory passages. The food will be then routed to the esophagus and in cases where it enters the larynx, a cough reflex is triggered to expel the substance and prevent it from continuing into the lungs. This protective reflex does

not work when a person is unconscious that is why it is not allowed to offer or administer fluids to an unconscious client. Vocal folds a pair of folds which is also called the true vocal cords that vibrate when air is expelled. Glottis the slit-like passageway between the vocal folds. Trachea Also called the windpipe, the trachea is about 10 to 12 cm long or about 4 incheas and travels dwon from the larynx to the fifth thoracic vertebra. This structure is reinforced with C-shaped rings of hyaline cartilage and these rings are very important for the following purposes: 1. The open parts of the rings about the esophagus that allows the structure to expand anteriorly when a person swallows a large size of food. 2. The solid portions of the C-rings are supporting the walls of the trachea to keep it patent or open even though pressure changes during breathing. The trachea is lined with ciliated mucosa that primarily serves for this purpose: To propel mucus loaded with dust particles and other debris away from the lungs towards the throat where it can either be swallowed or spat out. Main Bronchi The main bronchi, both the right and the left, are both formed by tracheal divisions. There is a slight difference between the right and left main bronchi. The right one is wider, shorter and straighter than the left. This is the most common site for an inhaled foreign object to become lodged. When air reaches the bronchi, it is already warmed, cleansed of most impurities and well humidified. Lungs The lungs are fairly large organs that occupy the most of the thoracic cavity. The most central part of the thoracic cavity, the mediastinum, is not occupied by the lungs as this area houses the heart. Apex the narrow superior portion of each lung and is located just below the clavicle Base the resting area of the lung. This is a broad lung area that rests on the diaphragm. Divisions of the Lungs The lungs are divided into lobes by the presence of fissures. The left lung has two lobes while the right lung has three. Pleural Layers Visceral pleura also termed as the pulmonary pleura and covers each surface of the lings. Parietal pleura covers the walls of the thoracic cavity. Pleural fluid a slippery serous secretion that allows the lungs to slide along over the thorax wall during breathing movements and causes the two pleural layers to cling together. Bronchioles smallest air-conducting passageways. Bronchial tree or respiratory tree a network formed due to the branching and rebranching of the respiratory passageways within the lungs.

Alveoli air sacs. This is the only area where exchange of gases takes place. Millions of clustered alveoli resembles bunches of grapes and these structures make up the bulk of the lungs. Respiratory Zone this part includes the respiratory bronchioles, alveolar ducts, alveolar sacs, alveoli. Physiology of Respiration The respiratory primarily supplies oxygen to the body and disposes of carbon dioxide through exhalation. Four events chronologically occur, for respiration to take place. 1. Pulmonary ventilation this process is commonly termed as breathing. With pulmonary ventilation, air must move out into and out of the lungs so that the alveoli of the lungs are continuously drained and filled with air. 2. External respiration this is the exchange of gases or the loading of oxygen and the unloading of carbon dioxide between the pulmonary blood and alveoli. 3. Respiratory gas transport this is the process where the oxygen and carbon dioxide is transported to the and from the lungs and tissue cells of the body through the bloodstream. 4. Internal respiration in internal respiration the exchange of gases is taking place between the blood and tissue cells. Mechanics of Breathing Breathing, also called pulmonary ventilation is a mechanical process that completely depends on the volume changes occurring in the thoracic cavity. Thus, a when volume changes pressure also changes, and this would lead to the flow of gases equalizing with the pressure. Inspiration also called inhalation. This is the act of allowing air to enter the body. Air is flowing into the lungs with this process. Inspiratory muscles are involved with inspiration which includes: 1. The diaphragm 2. External intercostals These muscles contract when air is flowing in and thoracic cavity increases. When the diaphragm contracts it slides inferiorly and is depressed. As a result the thoracic cavity increases. The contraction of the external intercostal muscles lifts the rib cage and thrusts the sternum forward. This increases the anteroposterior and lateral dimensions of the thorax. Expiration also called expiration. It the process of breathing out air as it leaves the lungs. This process causes the gases to flow out to equalize the pressure inside and outside the lungs. Under normal circumstances, the process of expiration is effortless. ANATOMY AND PHYSIOLOGY OF THE HUMAN LUNG-AN OVERVIEW The lungs are the primary organs of the respiratory system. The main function of the human respiratory system is to transport oxygen from the atmosphere into the blood, and to expel carbon dioxide from the body. Healthy levels of oxygen are absolutely crucial for the human body, as oxygen gives our cells energy and helps them regenerate. The Anatomy Of The Lung Each lung is divided into lobes. The right lung, which has three lobes, is slightly larger than the left, which has two. The lungs are housed in the chest cavity, or thoracic cavity, and covered by a protective

membrane called the pleura. The diaphragm, the primary muscle involved in respiration, separates the lungs from the abdominal cavity. The pulmonary arteries carry de-oxygenated blood from the right ventricle of the heart to the lungs. The pulmonary veins, on the other hand, carry oxygenated blood from the lungs to the heart, so it can be pumped to the rest of the body.

How The Lungs Work The lungs expand upon inhalation, or inspiration, and fill with air. They then return to their resting volume and push air out upon exhalation, or expiration. These two movements make up the process of breathing, or respiration. The respiratory system contains several structures. When you breathe, the lungs facilitate this process: 1. Air comes in through the mouth and/or nose, and travels down through the trachea, or "windpipe." This air travels down the trachea into two bronchi, one leading to each lung. The bronchi then subdivide into smaller tubes called bronchioles. The air finally fills the alveoli, which are the small air sacs at the ends of the bronchioles. 2. In the alveoli, the lungs facilitate the exchange of oxygen and carbon dioxide to and from the blood. Adult lungs have hundreds of alveoli, which increase the lungs' surface area and speed this process. Oxygen travels across the membranes of the alveoli and into the blood in the tiny capillaries surrounding them. 3. Oxygen molecules bind to hemoglobin in the blood and are carried throughout the body. This oxygenated blood can then be pumped to the body by the heart. 4. The blood also carries the waste product carbon dioxide back to the lungs, where it is transferred into the alveoli in the lungs to be expelled through exhalation. Smoking can damage the alveoli and make breathing labor intensive, resulting in emphysema or lung cancer. Types Of Respiration Two types of respiration exist: y Quiet respiration happens when the body is at rest. During quiet respiration, the diaphragm contracts and pulls down, lowering the pressure in the lungs and causing air to enter the lungs through the mouth and nose to equalize the pressure. When the diaphragm relaxes, it moves back up, pushing air back out of the lungs. The lungs and chest walls also return to their resting positions. This also reduces the size of the chest cavity and helps to push air out of the lungs.

Active respiration occurs when the body is active and requires higher levels of oxygen to the blood than when resting. During active respiration, the muscles around the ribs raise and push out the ribs and sternum, which increases thoracic volume, helping the lungs take in more air. During exhalation, the intercostals force the ribs to contract, and the abdominal muscles contract, forcing the diaphragm to rise. Both these movements make the thoracic cavity contract, and help push air out of the lungs.

The Lungs' Protections Several lung parts and functions act as protective mechanisms to keep out irritants and foreign particles. The hairs and mucus in the nose prevent foreign particles from entering the respiratory system. The breathing tubes in the lungs secrete mucus, which also helps protect the lungs from foreign particles. This mucus is naturally pushed up toward the epiglottis, where is passed into the esophagus and swallowed. Coughing up any of this mucus is usually an indication of a respiratory infection, or a condition such as bronchitis or chronic obstructive pulmonary disease (COPD). Irritants can also cause bronchospasm, in which the muscles around the bronchial tubes constrict in order to keep out irritants. Asthma involves inflammation and constriction of the bronchial tubes, and is often triggered by environmental irritants. Bronchial constriction causes breathing difficulties. About Breathing Difficulties Damage to any part of the respiratory pathway can also cause breathing difficulties. Understanding human lung anatomy and physiology makes clear how the different lung parts are affected in disease. In people with bronchitis, the bronchial tubes become inflamed and irritated. They produce mucus, resulting in a cough. Bronchitis can be acute, with a sudden onset and quick recovery, or chronic, and last much longer. Chronic obstructive pulmonary disease (COPD) involves symptoms of both chronic bronchitis and emphysema. Blockage in the bronchioles and alveoli make it difficult to exhale. This traps air in the lungs and in turn makes proper inhalation difficult. Interstitial lung disease, including pulmonary fibrosis, causes a buildup of scar tissue in the lungs and reduces lung function. Any of these conditions affect not only the lungs, but the entire body, as the healthy respiration is required to supply oxygen to the body and its organs.

VI. Laboratory Examinations/Diagnostic Exams A. Sputum Cytology Purpose: Sputum cytology examines a sample of sputum (mucus) under a microscope to determine whether abnormal cells are present. Sputum is not the same as saliva. Sputum is produced in the lungs and in the airways leading to the lungs. Sputum has some normal lung cells in it. Result of the Sputum Cytology: Abnormal cells are present in the sputum sample. Indication: Abnormal cells may indicate lung conditions such as pneumonia, inflammation, the buildup of asbestos fibers in the lungs (asbestosis), or lung cancer. B. Chest X-Ray Purpose: An x-ray (radiograph) is a noninvasive medical test that helps physicians diagnose and treat medical conditions. Imaging with x-rays involves exposing a part of the body to a small dose of ionizing radiation to produce pictures of the inside of the body. Result of the Chest X-Ray: cloudy projections around the medial right hemithorax and surrounding tissues seen with an 8 cm circumference lobulated mass noted on the upper left lobe of the lung. Indication: Possible cancer cell growth but a needle biopsy is still needed to confirm the diagnosis. C. Needle Biopsy Purpose: A needle biopsy, also called a needle aspiration, involves removing some cellseither surgically or in a less invasive procedure involving a hollow needlefrom a suspicious area within the body and examining them under a microscope to determine a diagnosis. Histopathology: Metastatic Undifferentiated Large Cell Carcinoma Indication: Confirmed of having Non-Small Cell Lung Carcinoma.

NURSING CARE PLAN

Assessment Subjective:  Dyspnea Objective:  Presence of crackles on both lung fields upon auscultation use of accessory muscles

Nursing Diagnosis Planning Nursing Interventions Rationale Ineffective Breathing Short Term: - Establish rapport - To gain pt/ SOs Pattern RT trust and cooperation After 3 hours of Decreased Lung nursing - Monitor and record - To obtain baseline Volume Capacity interventions the vital signs data secondary to patient will accumulation of - Assess breath sounds, - To note for fluid in the pleural demonstrate respiratory rate, depth and respiratory space as evidenced appropriate coping behaviors rhythm abnormalities that by presence of may indicate early crackles on both lung and methods to respiratory fields, dyspnea and improve breathing compromise and the verbalization of pattern. hypoxia the patient marigatan nak nga Long term: umanges talaga. - To promote lung After 1 to 2 days - Elevate head of the pt. expansion of nursing interventions, the - To promote patient would be adequate rest periods able to apply - Provide relaxing to limit fatigue techniques that environment would improve - To maximize breathing pattern - Administer supplemental oxygen available for and be free from oxygen as ordered cellular uptake signs and symptoms of -Assist client in the use of -To provide relief of respiratory relaxation technique causative factors distress. - Administer prescribed medications as ordered - For the pharmacological management of the patients condition

Expected Outcome Short Term: The patient shall have demonstrated appropriate coping behaviors and methods to improve breathing pattern. Long term: The patient shall have applied techniques that improved breathing pattern and be free from signs and symptoms of respiratory distress AEB respiratory rate within normal range, effective breathing and minimal use of accessory muscles during breathing.

-Maximize respiratory effort with good posture and effective use of accessory muscles.

-To promote wellness

-Encourage adequate rest periods between activities - to limit fatigue

Nursing Dx Planning Nursing Interventions Acute pain related to Short Term: - Assess patient pain for inflammation of intensity using a pain Verbalization of parietal pleura After 3-4 hours of rating scale, for location patient nasakit secondary to pleural nursing and for precipitating tuy barukong ku effusion as interventions, the factors. patients pain will manifested by Objective: restlessness, facial decrease from 7 to - Assess the response to 3 as verbalized by medications every 5 grimacing upon (+) DOB movement, report of the patient. minutes a pain scale of 7 nd the verbalization of Long Term: Restlessness the patient, nasakit After 2-3 days of Facial grimaces tuy barukong ku nursing upon movement interventions, the patient will Reports of pain on - Provide comfort demonstrate the chest area, measures. activities and described as sharp behaviors that will provoked by prevent the breathing nonrecurrence of pain. -Establish a quiet radiating, with a environment. pain scale of 7 out of 10 - Elevate head of bed.

Assessment Subjective:

Rationale Expected Outcome -To identify intensity, Short Term: precipitating factors and location to assist Patient shall have verbalized in accurate diagnosis. a decrease in pain from a scale of 7 to 3. - Assessing response determines effectiveness of medication and whether further interventions are required. Long Term: The patient shall have demonstrated activities and behaviours that will prevent the recurrence of pain.

- To provide nonpharmacological pain management. -A quiet environment reduces the energy demands on the patient. - Elevation improves chest expansion and oxygenation.

- Chest pain is often Teach patient relaxation precipitated by techniques and how to use emotional stress that them to reduce stress. can be relieved nonpharmacological measures such as relaxation.

Assessment Subjective: (none) Objective: Patient manifested: generalized weakness limited range of motion as observed use of accessory muscles during breathing (+) DOB

Nursing Diagnosis Planning Nursing Interventions Rationale Activity intolerance Short Term: - Establish Rapport - To gain clients related to participation and insufficient oxygen After 3-4 hours of cooperation in the for activities of daily nursing nurse patient living secondary to interventions, the interaction patient will use accumulation of - Monitor and record Vital - To obtain baseline fluid in the pleural identified Signs data techniques to space as manifested improve activity by generalized - Assess patients general - To note for any weakness, limited intolerance condition abnormalities and range of motion, use deformities present Long Term: of accessory muscles within the body during breathing and the verbalization of After 2-3 days of - To prevent strain the patient, Han ku nursing - Adjust clients daily and overexertion nga makaya unay ti interventions, the activities and reduce patient will report intensity of level. agkuti wenu measurable agtrabaho. increase in activity - Instruct client in - To conserve energy intolerance. unfamiliar activities and and promote safety in alternate ways of conserve energy - Encourage patient to have adequate bed rest and sleep -To relax the body

Expected Outcome Short Term: The patient shall have used identified techniques to improve activity intolerance. Long Term: The patient shall have reported measurable increase inactivity intolerance.

- To provide - Provide the patient with relaxation a calm and quiet environment - Assist the client in ambulation - To prevent risk for falls that could lead to injury

- Fatigue affects - Note presence of factors both the clients that could contribute to actual and perceived fatigue ability to participate in activities

- Ascertain clients ability to stand and move about and degree of assistance needed or use of equipment

- To determine current status and needs associated with participation in needed or desired activities

Generic Name Tramadol HCl 37.5 mg, paracetamol 325 mg

Brand Name Dolcet

Indications

Mechanism of Action Analgesic

Contraindications

Adverse Effect CNS & GI disturbances. Nausea, dizziness, somnolence. Asthenia, fatigue, hot flushes, constipation, diarrhea, flatulence, dry mouth, pruritus, increased sweating, tinnitus.

Nursing Responsibilities

Moderate to severe pain.

Acute intoxication w/ alcohol, hypnotics, narcotics, centrally-acting analgesics, opioids or psychotropic drugs. Hypersensitivity.

y y

Asses for level of pain relief and administer dose as needed but not to exceed the recommended total daily dose Discontinue drug and notify the if hypersensitivity occur Take appropriate safety precautions To be taken with food to avoid GI upset

Generic Name Salbuipratropium Bromide .5 mg. 3 doses

Brand Name Budesonide inhalation

Indications

Mechanism of Action Corticosteroid

Contraindications

Adverse Effect weakness, tired feeling, nausea, vomiting, feeling like you might pass out; wheezing or breathing problems after using this medication ; worsening respiratory symptoms; ear pain with fever; vision problems.

Nursing Responsibilities y Make sure patient does not cut, crush, or chew capsules; they must be swallowed whole. y Encourage patient to complete full 8 wk of drug therapy. y Do not take this drug with grapefruit juice; avoid grapefruit juice entirely while using this drug. y Report chest pain, ankle swelling, respiratory infections, increased bruising.

Difficulty of breathing

Acute intoxication y w/ alcohol, hypnotics, narcotics, centrally-acting analgesics, opioids or psychotropic drugs. Hypersensitivity. y

y y

Generic Name Dextromethor -phan Hbr 10 mg.

Brand Name Benyllin

Indication

Mechanism of Action On-Opioid Anti-tussive

Contraindications

Adverse Effect

Nursing Responsibilities y
Dextromethorph an 15 to 30 mg is equivalent to codeine 8 to 15 mg as an antitussive. Drug produces no analgesia or addiction and little or no CNS depression. Use drug with chest percussion and vibration. Monitor cough type and frequency.

Control of NonProductive Cough

- This drug should not confusion be used with the constipation following medications dizziness because very serious drowsiness interactions may nausea occur: MAO inhibitors vomiting (e.g., y . furazolidone, isocarbo xazid, linezolid, moclobemide, phenelzine, procarbazi ne, rasagiline, selegiline, tranylcypro mine). - During pregnancy, this medication should be used only when clearly needed.