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NURSING CARE PLAN – Lung Cancer ASSESSMENT SUBJECTIVE: “Nakakaranas ako ng hingal sa paghinga at panankit ng dibdib” (Lately, I've
been experiencing shortness of breath and chest pains) as
DIAGNOSIS Impaired gas exchange related to altered oxygen supply.
INFERENCE Cancer is a class of diseases characterized by out-of-control cell growth, and lung cancer occurs when this uncontrolled cell growth begins in one or both lungs. Rather than developing into healthy, normal lung tissue, these abnormal cells continue dividing and form lumps or masses of tissue called tumors. Tumors interfere with the main function of the lung, which is to provide the bloodstream with oxygen to be carried to the entire body. If a tumor stays in one spot and demonstrates limited growth, it is generally
PLANNING After 8 hours of nursing intervention the patient will demonstrate improved ventilation and adequate oxygenation of tissues by ABGs within patient’s normal range.
INTERVENTION INDEPENDENT: • Note respiratory rate, depth, and ease of respirations. Observe for the use of accessory muscles, pursed lip breathing, changes in skin or mucous membrane color. •
RATIONALE Respiration may be increased as a result of pain or as an initial compensatory mechanism to accommodate for loss of lung tissue. Increased work of breathing and cyanosis may indicate increasing oxygen consumption and energy expenditures and reduced respiratory reserve. Consolidation and lack of air movement on operative side are normal in the pneumonectomy patient. May indicate increased hypoxia or complications such as mediastinal shift in pneumonectomy patient when accompanied by tachypnea, tachycardia, and
EVALUATION After 8 hours of nursing intervention the patient was able to demonstrate improved ventilation and adequate oxygenation of tissues by ABGs within patient’s normal range.
verbalized by the patient OBJECTIVE: • • • • Restlessnes s Cyanosis Changes in mentation V/S taken as follows T: 37.1 ˚C P: 101 R: 25 BP: 120/ 80
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Auscultate lungs for air movement and abnormal breath sounds.
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Investigate restlessness and changes in mentation or level of consciousness.
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considered to be benign. More dangerous, or malignant, tumors form when the cancer cells migrate to other parts of the body through the blood or lymph system. When a tumor successfully spreads to other parts of the body and grows, invading and destroying other healthy tissues, it is said to have metastasized. This process itself is called metastasis, and the result is a more serious condition that is very difficult to treat. Lung cancer is called "primary" if the cancer originates in the lungs and "secondary" if it originates elsewhere in the body but has tracheal deviation. Airway obstruction impedes ventilation, impairing gas exchange. Maximizes lung expansion and drainage of secretions. Positioning the patients following lung surgery with their “good lung down” maximizes oxygenation by using gravity to enhance blood flow to the healthy lung, creating the best possible match between ventilation and perfusion. Promotes maximal ventilation and oxygenation and reduces or prevent atelectasis.
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Maintain patent airway by positioning, suctioning, use of airway adjuncts. Reposition frequently, placing patient in sitting positions and supine to side positions. Avoid positioning patient with a pneumonectomy on the operative side. Favor the “good lung down” position.
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Encourage or assist with deep breathing exercises and pursedlip breathing as appropriate.
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DEPENDENT: • Administer supplemental oxygen via nasal cannula, partial rebreathing
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Maximizes available oxygen, especially while ventilation is reduced because pain.
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metastasized to the lungs. These two types are considered different cancers from diagnostic and treatment perspectives. mask, or high humidity face mask as indicated. Monitor graph of ABGs, pulse oximetry readings.
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Decreasing Pao2 or increasing PaCO2 may indicate need for ventilatory support.