case presentation final2
TRANSCRIPT
A Case StudyPresented to the Faculty of
The Ateneo de Davao UniversityCollege of Nursing
CASE PRESENTATION: Lung Adenocarcinoma
Submitted to:Mr. Roy Cresencio R. Linao, Jr. RN
Clinical Instructor – Panelist for the Case Study
Submitted by:
Eliez Anne M. DayanghirangDeana Charise Delima
Gil Albert DoromalAna Patricia DujaliKevin Sam Eliseo
Fiel Ronan Leo FortezKatreena GalangKiershane JovenKristian Jake Lad
Almira Latip
BSN-3F
July 2009
TABLE OF CONTENTSTable of Contents....................................................................................................................................... iAcknowledgement.................................................................................................................................... ii
Chapter
I. Introduction...................................................................................................................................1
II. Objectives (General & Specific)..........................................................................................3
III. Patient’s Data................................................................................................................................ 5
IV. Family Background and Health History........................................................................7
V. Developmental Data................................................................................................................. 11
VI. Definition of Complete Diagnosis......................................................................................16
VII. Physical Assessment.................................................................................................................20
VIII. Anatomy and Physiology........................................................................................................22
IX. Etiology and Symptomatology............................................................................................27
X. Pathophysiology..........................................................................................................................34
XI. Doctor’s Order..............................................................................................................................44
XII. Diagnostic Exam.......................................................................................................................... 48
XIII. Drug Study...................................................................................................................................... 55
XIV. Surgical Procedure.................................................................................................................... 74
XV. Nursing Theories........................................................................................................................ 82
XVI. Nursing Care Plan.......................................................................................................................86
XVII. Prognosis /Discharge Plan (M. E. T. H. O. D.)..............................................................98
XVIII. Recommendation....................................................................................................................... 104
XIX. References...................................................................................................................................... 107
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ACKNOWLEDGEMENTThe group would like to extend their warmest gratitude to the following people who
played a vital role in the success of this study:
First, to the Almighty Creator for giving us the wisdom, knowledge, and strength
that enabled us to understand, recognize, and overcome all the trials, difficulties, and
sleepless nights in doing this case study.
To the group’s clinical instructor, Mr. Roy Cresencio Linao, Jr. R.N for his never
ending patience, guidance and support throughout this case study.
To the staff of Davao Medical School Foundation, particularly in the Operating
Room, for allowing us to conduct this study and research, and making our stay a superb
and unforgettable experience.
To the client and her significant others for their willingness to share their personal
data for the fulfillment of this study.
To the group’s loved ones, family, and friends, who served as their inspirations to
persevere and continue in their endeavor.
Lastly, to each and every member of the group, for their time and effort to conclude
this study.
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INTRODUCTIONIn 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 Beachin’ Barato’s case primarily because they would like to broaden their
knowledge on lung cancer. Since there is a notion that those who have lung cancers are smokers, we
have been struck with the fact that our patient has never had any involvement with smoking. In
addition, the group’s learnings on the Perioperative Concepts will be applied in Beachin’ Barato’s
case, helping them improve their skills as operating room nurses.
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OBJECTIVESGeneral Objective:
The main objective of the group in conducting this case study is to be able to evaluate and have a
firm background on the health condition of the patient and her needs associated to lung cancer so that
proper planning, management and intervention will be given to meet basic needs, alleviate sufferings
and prevent complications.
In order to meet the main objective, the group has:
To establish rapport;
To set our goals that will guide us through the course of the study;
To have a background on lung cancer statistics as an introductory of the case study;
To be able to have a clear picture of the patient’s family background and health history;
To be able to define the level or stage of the patient in the aspect of her developmental data
basing on the theories of Erickson, Peck, Havighurst and Piaget;
To define the patient’s complete diagnosis through different sources and references;
To conduct a cephalocaudal physical assessment and determine abnormalities essential to this
study;
To have a background on the effects of the condition on the patients anatomy and physiology;
To present the basic Etiology and Symptomatology associated with the disease;
To be able to establish a thorough systemic pathophysiology as the foundation of the origin of the
disease;
To evaluate the doctor’s order to promote health and prevent further complications;
To review diagnostic exams performed to the patient as the basis for accurate interventions;
To analyze recommended drugs taken by the patient through a precise drug study;
To establish facts about the surgical procedure/s done to the patient;
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To identify nursing theories applicable to the patient’s condition;
To formulate realistic nursing care plans;
To establish discharge plan in promoting patient’s wellness;
To present recommendations for patient’s fast recovery, continuity of care and holistic welfare.
PATIENT’S DATA
Personal Data:
Patients Name: Beachin’ Barato
Age: 65 years old
Gender: Female
Birth date: December 11, 1942
Address: Davao City
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Nationality: Filipino
Religion [Domination]: Christianity [Roman Catholic]
Civil Status: Married
Educational Attainment: High School Graduate
Occupation: Retired High School Teacher for 10 years
Weight: 62 kilograms
Clinical/ Admitting Data:
Date of admission: July 2, 2009
Time of admission: 9:30 am
Hospital: Davao Medical School Foundation Davao City [1604730]
Ward [Room & Bed
Numbers]:
H244
Attending Physician: Dr. Allan P. Arreola
Chief complaint: Difficulty breathing
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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------------rapid breathing!!!!!!!!!!
130/ 90 Millimeters per Mercury
Chest Tube Thoracostomy
*Pre-operation Diagnosis: Massive left pleural effusion secondary to lung cancer
*Surgeon: Dr. Lei*Anesthesiologist: Dr. Barinaga
Source of information: Patient; Patient’s daughter-in-law; Husband
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FAMILY BACKGROUND AND HEALTH HISTORY
HEALTH BACKGROUND
A. Family Background
Beachin’ Barato (not her real name), 65 years old was born in Misamis
Occidental, on December 11, 1942. She spent majority of her childhood there but was
separated with her family during the Philippine-Japanese war. In fact, she does not know
who her real parents and siblings are. She acquired formal education up to high school
while living in an orphanage. She met her current husband, Mr. Optimus Prime (engineer),
who is from Davao, in Misamis. Optimus Prime was working as an engineer in Misamis
when they met. The couple decided to marry in Davao, where the family of Optimus Prime
can witness the wedding and provide support to the couple, who are still starting out as a
young family.
The couple have three children, all of which are boys. Their sons got formal
education in Davao City National High School. Moreover, all are college graduates in
different universities and colleges. Mr. Optimus Prime had a stable job working as an
engineer and was their main source of income. Beachin’ Barato was a devout Catholic,
joining church organizations and becoming an active member in their mission of “enriching
their faith, while recruiting others along the way”, as Beachin’ Barato remarked. This
provided her good experience to be a teacher of Religion in Davao City National High
School for 10 years.
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Beachin’ Barato has nine grandchildren, three for each sons. She only has two
granddaughters. Beachin’ Barato’s sons have become successful in their chosen
professions, thus they had the means to afford good education for their children. Her eldest
son, Bumble Bee, is a manager at a telecommunications company. He has two sons in
college while her youngest daughter is still in high school. Her second son, Ironhide, is now
working in Pampanga as an engineer for the DPWH. His three sons are still in high school.
The third son, Jetfire is currently working as a manager at an oil company. He has two sons
and a daughter. The eldest is in high school while the younger children are in grade school.
B. History of Past Illness
The past illnesses that the patient has encountered in the past were not
significant. Only common minor illnesses such as fever, flu, and hyperacidity were
experienced by the patient in her lifetime. She did not experience severe, yet common
diseases such as dengue and measles. Also, she has no diabetes mellitus. She has no history
of food and drug allergies or hypersensitivities. She and the entire family, according to her,
do not smoke. Also, consuming alcoholic beverages was something she did not do. A
notable health condition that she experienced is bronchial asthma. She coped with asthma
by finding a comfortable position during asthma attacks and she did not take any
medications because those were not available yet. Her asthma subsided when she was
about 40 years old. A significant disease that she encountered (and is still encountering)
later on in her life is hypertension. She was diagnosed after getting her routine blood
pressure checkup. The doctor advised her to avoid salty and fatty foods and she was also
given medicine, specifically amlodipine besylate- Norvasc.
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Medications she took in her lifetime were not numerous, according to her. In fact,
she said she hardly ever took medications. Paracetamol was always her first choice
whenever she encounters fever and colds. She also took some Neozep and mefenamic acid
in her lifetime. Also, the patient noted that she had to comply with taking Norvasc for her
hypertension.
C. Present Health History
The 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. She also minimized
eating her favorite food, which is pork, for the sake of improving her hypertensive state.
She is currently in a pre-hypertensive state with a blood pressure of 130/90 mmHg. The
doctor’s first impression with her hypertension was that she was in Stage 2, thus we can
say that her condition has significantly improved.
The patient’s lung cancer was diagnosed when she was having an onset of difficulty
of breathing for three days when she was on a vacation in Pampanga last May 2009. As the
days went by, she noticed a progression of dyspnea. Initially, she thought that her asthma
had recurred, which prompted her to seek consultation on June 2009. After a series of
diagnostic procedures, she was then diagnosed of having lung cancer. The cancer was
classified as adenocarcinoma, or a cancer originating in the mucus producing glands in the
lungs. It is known to be the most common cancer in lifelong non-smokers.
On July 2, 2009, upon receiving the chest x-ray result, her physician, Dr. Arreola,
ordered a STAT chest tube thoracostomy. Dr. Lei performed the procedure with the help of
Dr. Barinaga as the anesthesiologist.
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D. Effects/ Expectations of Illness to Self/ Family
The response of the family and the patient upon knowing that cancer was the
diagnosis was not very negative. When the diagnosis was made, the family made sure that
all possible care should be given to Beachin’ Barato, thus hinting they were positive about
the disease and they were on the optimistic side that Beachin’ Barato can still be cured. The
patient, however, was not quite as optimistic as her family but was still not negative about
her condition. The sons of Beachin’ Barato are profoundly concerned, consequently, they
are frequently visiting their mother along with their children to give support to their ailing
mother. The wife of her second son, Starscream was particularly very supportive of her
mother-in-law. She was also our informant, and we were amazed at how she knows the
family, especially Beachin’ Barato, very well. When we met Starscream, she was the only
person who accompanied Beachin’ Barato to the operating room which manifests the love
that this family has for each other.
The patient verbalized that lung cancer was the last thing that she thought that she
would encounter. At first, she said she felt a sense of disbelief and shock but as time passed
by she accepted the fact that she had the disease. She uttered, “Kung panahon mo na talaga,
panahon mo na. Tingnan mo ako, di nga ako naninigarilyo tapos magkaka-lung cancer ako.
May mga paraan talaga ang Panginoon. Although ganoon na nga ang sitwasyon, sana lang
nga gumaling ako. Yan ang ipinagdadasal ko every day.”
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Schrema Prime
Sam Witwicky
Lady Gaga
Mikaela Banes
John Smith Pugad Babay
Lasing Torres
PocahontasMudflapArmy NavyArmy Captain
Megatron Shaggy Mr. Boombastick
Elephantastic
Beachin’Barato
RobertiJaworski
Mr. Lover Lover
Legend: Male
Female
Client
*unable to identify status (living or deceased); health history (diabetic, hypertensive, etc) because client cannot provide information
GENEALOGY
DEVELOPMENTAL DATA
Developmental data is an increase in the complexity of function and skill progression. It is the capacity and skill of a person to adapt to
the environment. It is the attainment of intelligence, and it is a problem-solving ability, which begins in infancy stage and ends in the old age
stage.
A variety of factors influence an individual’s developmental stage. Heredity guides every aspect of physical, cognitive, social, emotional,
and personality development. Family members, peer groups, the school environment, and the community influence how a person think,
socialize, and become self-aware. Biological factors such as nutrition, medical care, and environmental hazards in the air and water affect the
growth of the body and mind. Economic and political institutions, the media, and cultural values all guide how a person live their lives. Critical
life events, such as a family crisis or a national emergency, can alter the growth of personality and identity. Most important of all, a person
contributes significantly to their own development. This occurs as they strive to understand their experiences, respond in individual ways to
the people around them, and choose activities, friends, and interests. Thus, the factors that guide development arise from both outside and
within the person. The researchers believe that Ms. Bichin’ Barato is generally at the right path. Evidences are clear, well established and best
explained in the table below.
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Robert Peck’s adult development theory
In past, development was viewed as complete by the time of physical maturity, and aging was considered a decline following maturity.
The emphasis was on the negative rather than on the positive aspects of aging. However, Robert peck believes that although physical
capabilities and functions decreases with old age, mental and social capabilities tend to increase in the latter part of life. And so, like others,
miss A is also subjected to Peck’s three developmental tasks necessary at her age.
Tasks Description Result Justification
-Ego differentiation versus work-role preoccupation
-Body transcendence versus body preoccupation
-Ego transcendence versus ego preoccupation
- An adult’s identity and feeling of worth are highly dependent on that persons work role.
- This task calls for an individual to adjust to decreasing physical capacities and at the same time maintain feelings of well-being. Preoccupation with declining body functions reduces happiness and satisfaction with life.
- Ego transcendence is the acceptance without fear of one’s death as inevitable. This acceptance includes being actively involve in one’s own future beyond death. Ego
ACHIEVED
ACHIEVED
ACHIEVED
- It can be said that although the patient cannot do her routinely activities without the partial aid of the nurse and that she cannot teach anymore, she is well aware of her body capability and accepts the things she cannot do. Thus, the patient belongs to ego differentiation aspect.
-During the interview, the patient is aware of her decreasing muscle strength and that she accepts her deteriorating body function. She always manages to adapt with it with the help of her children. Thus, body transcendence is prevalent.
-c
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preoccupation by contrast, results in holding into life and a preoccupation on self-gratification.
Psychosocial Theory of Development by Erik Erikson
Erik Erikson describes 8 stages of development. Hhe envisions life as a sequence of levels of each stage signals a task that must be
achieved. The 8 tages reflects both positive and negative of critical life periods. The developmental tasks can be viewed as a series of crisis and
successful resolution of these crises is supportive to person’s ego and likewise failure to resolve the crises is damaging to the ego.
Stage Description Result JustificationIntegrity vs. Despair
This involves reflecting on the past and either piercing together a positive review or concluding that ones life has not been well spent.
ACHIEVED A clear understanding of patient’s life is necessary. It can be said that her satisfaction on her life was achieved. She even told us about her past experiences and the places she had been. She smiles when she talked about her children and how successful they were. There is an acceptance of worth and uniqueness of her own life and the acceptance of death. Despite of her declining strength she was able to gain wisdom and understanding. Thus, it can be concluded that the patient achieves integrity.
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Robert Havighurst’s Developmental Milestones Theory
Robert Havighurst believed that learning is basic to life and that people continue to learn throughout life. A developmental task is a
task which arises at or about a certain period in the life of an individual, successful, achievement of which leads to his happiness and to success
with the later tasks, while failure leads to unhappiness in the individual, disapproval by society and difficulty with later tasks.
Stage Description Result JustificationLater maturity stage
In this stage, once that the later maturity had been established and reached it is expected that the person will do the following:
Adjusting to decreasing physical strength and health
Adjusting to requirements and reduced incomes
Establishing an explicit affiliation with once age groups
Establishing satisfactory physical living arrangements.
ACHIEVED
ACHIEVED
ACHIEVED
ACHIEVED
- the patient is completely aware of her weakening body
-She is not working currently and that her children provided her of her basic needs
- Other than her children and grandchildren, she used to be with her husband and her friend in their neighborhood that has the same age as her.
-she is staying with her husband. More often than not, she visits her children and grandchildren
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Cognitive Theory of development of Jean Piaget
The best-known theory of cognitive development was developed by Swiss psychologist Jean Piaget, who became interested in how
children think and construct their own knowledge. Based on his studies and observations, Piaget theorized that children proceed through four
distinct stages of cognitive development. Cognitive development is an orderly, sequential process in which a variety of new experiences must
exist before intellectual abilities can develop.
Stage Description Result JustificationFormal Operational Stage:
In this stage individuals move beyond concrete experiences and think in abstract and more logical ways. As part of thinking more abstractly, an individual develop images of ideal circumstances. This describes how a person thinks systematically and uses more logical reasoning. It is also characterized thinking according to ethics and justice. They can also reason about hypothetical possibilities and deduce new concepts.
ACHIEVED One great manifestation of this stage is that a person is able to finish school, reason-out abstractly and logically, able to draw answers from information that is available, and able to apply whatever is being thought in school. The first one is not that important at all because in this country not are able to finish school at the right time. But the other manifestations that is correlated to this stage is greatly evident to Ms Beachin’ Barato. First, she was able to apply her learning's in her life experiences and shared this knowledge when she became a religion teacher in the City High School. She was well aware of her illness and seeks medical help whenever necessary. Though, her illness was a tough milestone, she was able to accept the truth on what was happening and continue to be concrete on her decisions and aspiration in life.
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DEFINITION OF COMPLETE DIAGNOSIS
MASSIVE PLEURAL EFFUSION secondary to LUNG CANCER
“Pleural effusion or pleurisy is the condition in which there is an accumulation of fluid in
the pleural space. The effusion is either transudates or exudates. Transudates are
associated with excess pleural fluid resulting from other condition such as congestive heart
failure, nephritic syndrome, or malnutrition. The fluid is clear or faintly yellow and watery
with less than 3 gm per 100 ml of protein. In comparison exudates are darker yellow or
even amber in color and clot when standing because exudates are formed primarily from
bacterial growth that causes infection and inflammation the protein count is high-more
than 3 gm per 100ml. Pleurisy with exudates is more often localized on one side...Pleural
effusion may be generalized with fluid accumulating freely in the pleural space and is more
associated with pneumonia, pulmonary infarction and metastatic tumors.”
“Lung cancer is the abnormal growth of cells, originates commonly at the bronchi and
continue to divide and spread throughout the lungs, lymphatic system and systemic arterial
circulation”
The clinical practice of Medical-surgical nursing (1988)By:Marjorie Beyers, R.N.,M.S.N and Susan Dudas, R.N.,M.S.N
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“Pleural effusion, a collection of fluid in the pleural space, is rarely a primary disease
process but is usually secondary to other diseases. Normally, the pleural space contains a
small amount of fluid (5 to 15 ml), which acts as a lubricant that allows the pleural surfaces
to move without friction... Bronchogenic Carcinoma is the most common malignancy
associated with pleural effusion.”
“Lung cancer arises from a single transformed epithelial cell in the tracheobronchial
airway. A carcinogen binds to cells DNA and damage it. This damage results to cellular
changes, abnormal cell growth, and eventually a malignant cell. As damage DNA passed on
to the daughter cells, the DNA undergoes further changes and becomes unstable. With
accumulation of genetic changes, the pulmonary epithelium undergoes malignant
transformation from normal epithelium to eventual invasive carcinoma.” (Kelly, 1997)
Cited on medical-surgical nursing vol. 1 (2000)By: Suzanne C. Smeltzer and Brenda G. Bare
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“Pleural effusion is a collection of fluid in the pleural space. It is not a disease, but rather a
sign of a serious disease. It kis frequently classified as transudative or exudative according
to whether the protein content of the effusion is low or high, respectively. A transudate
occurs primarily in non inflammatory conditions and is an accumulation of protein poor,
cell poor fluid. Transudative peural effusion (also called hydrothorax) are caused by (1)
increase hydrostatic pressure found in congestive heart failure (2) decrease oncotic
pressure (from hypoalbuminemia) found in chronic liver or renal disease. In those
situation fluid movement is facilitated out of the capillaries and into the pleural space.
An exudates is an accumulation of fluid and cells in the area of inflammation. An exudative
pleural effusion results from increase capillary permeability characteristic of an
inflammatory reaction.. examples of these type of effusion occur secondary to pulmonary
inflammation or malignancies.”
“Lung cancer is the abnormal growth and division of cells in the lungs that has two
dysfunction present in the process(1)dysfunction in cellular proliferation (growth) and (2)
dysfunction in the cellular differentiation (maturity)”
Medical- Surgical nursing: Assessment and management of clinical problems, Second edition (1999)
By: Sharon Mantik Lewis, R.N., Ph.D.Idolia Cox Collier R.N., D.N.Sc.
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PHSYICAL ASSESSMENTDate of Assessment: July 4, 2009
Time of Assessment: 5:25 pm
Location of Assessment: Davao Medical School Foundation Hospital
Vital Signs
Temperature : 36 degrees Celsius
Pulse Rate: 87 Beats per Minute
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.
She is calm and responsive. The patient has an endomorph type of body; with a height of 158.49
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centimeters or 62.4 inches and with a weight of 62 kilograms or 136.4 pounds. Patient had already
done her general and oral hygiene and was dressed appropriately for the occasion.
Skin
Her skin color is normal, appears thin and translucent, dry and flaky over the extremities.
Skin lost its elasticity and takes longer to return to its natural shape after being tented between the
thumb and finger. The palms and the soles are calloused. Wrinkles appear on the skin of the face
and neck. Freckles are also noted on the back of the hand. Incision site is 2 cm on the lateral thorax
on the 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
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.
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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.
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.
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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 , her chest was not symmetrical due to the
surgical site and the spine was vertically aligned from the neck to the buttocks. There was a full and
symmetric chest expansion. The anteroposterior diameter of the chest widens because of barrel-
chested appearance. Upon auscultation, no adventitious sounds can be heard.
Heart
The 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. There were also no discharges in the patient’s
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nipples. Breast is noted to be saggy in contour and in shape as a sign of breastfeeding and child
birth.
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
The patient declined to assess her 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 her upper and lower quadrants and on both upper and lower extremities.
Weakness and pain were noted at the upper left extremity of the patient near the incision or
surgical part. There is no missing finger or bone enlargement on the hands and wrists.
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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.
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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
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
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undifferentiated carcinoma. This cancer forms near the surface, or outer edges, of the lungs. It can
grow rapidly.
The second type of lung cancer is the Small cell Lung Cancer. SCLC accounts for about 20% of all
lung cancers. Although the cells are small, they multiply quickly and form large tumors that can
spread throughout the body. Smoking is almost always the cause of SCLC.
Adenocarcinoma
Like other cancers, adenocarcinoma is the growth of abnormal cells. These cancerous cells
multiply out of control and form a tumor. As the tumor grows, it destroys parts of the lung.
Eventually, the tumor's abnormal cells can spread (metastasize) to other parts of the body,
including the local lymph nodes in the chest and the central portion of the chest, called the
mediastinum; the liver; the bones; the adrenal glands; and other organs, including the brain.
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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Stages of Non-small Cell Lung Cancer
Occult (hidden) stage:
In the occult (hidden) stage, cancer cells are found in sputum (mucus coughed up from the lungs),
but no tumor can be found in the lung by imaging or bronchoscopy. Sometimes, the primary tumor
is too small to be checked.
Stage 0 (carcinoma in situ):
In stage 0 (carcinoma in situ), cancer is in the lung only and has not spread beyond the innermost
lining of the lung.
Stage I is divided into stages IA and IB:
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Stage IA: The tumor is in the lung only and is 3 centimeters or smaller.
Stage IB: One or more of the following is true:
--The tumor is larger than 3 centimeters.
--Cancer has spread to the main bronchus of the lung, and is at least 2 centimeters from the
carina (where the trachea joins the bronchi).
--Cancer has spread to the innermost layer of the membrane that covers the lungs.
--The tumor partly blocks the bronchus or bronchioles and part of the lung has collapsed or
developed pneumonitis (inflammation of the lung).
Stage II is divided into stages IIA and IIB:
Stage IIA: The tumor is 3 centimeters or smaller and cancer has spread to nearby lymph
nodes on the same side of the chest as the tumor.
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Stage IIB: Cancer has spread to nearby lymph nodes on the same side of the chest as the
tumor and one or more of the following is true:
--The tumor is larger than 3 centimeters.
-Cancer has spread to the main bronchus of the lung and is 2 centimeters or more from the
carina (where the trachea joins the bronchi).
--Cancer has spread to the innermost layer of the membrane that covers the lungs.
--The tumor partly blocks the bronchus or bronchioles and part of the lung has collapsed or
developed pneumonitis (inflammation of the lung).
Stage III is divided into stages IIIA and
IIIB:
In stage IIIA, cancer has spread to lymph nodes on the same side of the chest as the tumor. Also:
---The tumor may be any size.
---Cancer may have spread to the main
bronchus, the chest wall, the
diaphragm, the pleura around the
lungs, or the membrane around the
heart, but has not spread to the trachea.
---Part or all of the lung may have collapsed or developed pneumonitis (inflammation of the
lung).
In stage IIIB, the tumor may be any size and has spread:
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---To lymph nodes above the collarbone or in the opposite side of the chest from the tumor;
and/or
Stage IV
In stage IV, cancer may have spread to lymph
nodes and has spread to another lobe of the lungs
or to other parts of the body, such as the brain,
liver, adrenal glands, kidneys, or bone.
Recurrent
Non-Small
Cell Lung
Cancer
- is cancer
that has
recurred
(come
back) after it has been treated. The cancer may come back in
the brain, lung, or other parts of the body.
Treatment Option Overview
There are different types of treatment for patients with non-small cell lung cancer.
Different types of treatments are available for patients with non-small cell lung cancer. Some
treatments are standard (the currently used treatment), and some are being tested in clinical trials.
Before starting treatment, patients may want to think about taking part in a clinical trial. A
treatment clinical trial is a research study meant to help improve current treatments or obtain
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information on new treatments for patients with cancer. When clinical trials show that a new
treatment is better than the standard treatment, the new treatment may become the standard
treatment. Choosing the most appropriate cancer treatment is a decision that ideally involves the
patient, family, and health care team.]
Pleural Effusion 2o Lung Cancer
Going back to the information given about pleura, it produces a fluid which acts as a lubricant
that helps you breathe easily, allowing the lungs to move in and out smoothly. When one has cancer, the
cells will work abnormally resulting to abnormal and excessive collection of this fluid. Too much of this
fluid can impair breathing by limiting the expansion of the lungs during inhalation and can build up
between the two layers of the pleura: this is called a pleural effusion.
Four main types of fluids in the pleural space are the serous fluid (hydrothorax), blood
(hemothorax), lipid (chylothorax), and pus (pyothorax or empyema). Classification of pleural effusion is
based on the mechanism of fluid formation and pleural fluid chemistry.
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Generally, pleural effusions are categorized into transudative or exudative effusions. In this
case, exudative effusions are present, which usually results from leaky blood vessels caused by
inflammation (irritation and swelling) of the pleura. This is often caused by lung disease. Examples
include lung cancer, lung infections such as tuberculosis and pneumonia, drug reactions,
and asbestosis.
Pleural effusion is usually diagnosed on the basis of medical history and physical exam, and
confirmed by chest x-ray and CT Scan.
Physical exam and history: An exam of the body to check general signs of health, including
checking for signs of disease, such as lumps or anything else that seems unusual. A history
of the patient’s health habits, including smoking, and past jobs, illnesses, and treatments
will also be taken.
Chest x-ray: An x-ray of the organs and bones inside the chest. An x-ray is a type of energy
beam that can go through the body and onto film, making a picture of areas inside the body.
Pleural effusion on the left lung.
CT scan (CAT scan): A procedure that makes a series of detailed pictures of areas inside the
body, such as the chest, taken from different angles. The pictures are made by a computer
linked to an x-ray machine. A dye may be injected into a vein or swallowed to help the
33 | P a g e
organs or tissues show up more clearly. This procedure is also called computed
tomography, computerized tomography, or computerized axial tomography.
C T scan showing right-sided
pleural effusion along with
compressive atelectasis in the
right lower lobe without
thickening of visceral or
parietal pleura.
34 | P a g e
ETIOLOGY and SYMPTOMATOLOGY
ETIOLOGY
PredisposingFactors
Present/ AbsentRationale Justification
Genetic predisposition
Absent The incidence of lung cancer in close relatives of clients with lung cancer appears to be two or three times that of the general population regardless of smoking status.Smeltzer, Suzanne C. Textbook of Medical-Surgical Nursing. 10h editionMutations in both the p53 gene and the K-ras oncogene are most commonly observed in lung cancer.Johnson, B.E., Kelly M.J.
The client does not report anyone in the family or kin having a lung cancer.
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PrecipitatingFactors
Present/ AbsentRationale Justification
Cigarette or tobacco smoking
Absent Tobacco use is responsible for more than one of every 6 deaths from pulmonary and cardiovascular disorder. More than 85% of lung cancers are attributable to inhalation of cigarette smoke. Lung cancer is 10 times more common in cigarette smokers than in non-smokers. The younger the person is when she started smoking, the greater the risk for developing lung cancer. The risk lessens when smoking cessation increases.Smeltzer, Suzanne C. Textbook of Medical-Surgical Nursing. 10th edition
According to the client, she never tried smoking in her entire life.
Second hand smoking Absent Passive smoking is blamed to be the second cause of lung cancer. In other words, people who involuntarily inhale tobacco or cigarette smoke in a closed environment are at an increased risk in developing lung cancer. There is a 35% risk for developing lung cancer to those who are exposed.Smeltzer, Suzanne C. Textbook of Medical-Surgical Nursing. 1oth edition
The client stated that there was no prolonged exposure to cigarette or tobacco smoke during her lifetime.
Dietary factors Absent Research documented that people who eat a diet low in fruits and vegetables are at risk for developing lung cancer. It has been hypothesized that
The client stated that she eats fruits especially every after dinner.
SYMPTOMATOLOGY
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Symptoms Present/Absent Rationale JustificationCough Present Cough is a natural protective
reflex against microorganisms. It signals the presence of disease and infection in the body, particularly respiratory disease and infection. It can be triggered by benign or malignant lung tumors or mediastinal masses. Smeltzer, Suzanne C. Textbook of Medical-Surgical Nursing. 10th edition
The client, upon assessment did not show any signs of cough. However, according to her daughter in-law, the client was experiencing cough with no sputum excretion, prior to knowing her final diagnosis.
Chest pain Absent Chest pain is a symptom in about one-fourth of people with lung cancer. The pain is dull, aching, and persistent and may involve other structures surrounding the lung.Smeltzer, Suzanne C. Textbook of Medical-Surgical Nursing. 10th edition
The client did not report any chest pain.
Shortness of breath Present Shortness of breath usually results from a blockage to the flow of air in part of the lung, collection of fluid around the lung (pleural effusion), or the spread of tumor throughout the lungs.Smeltzer, Suzanne C. Textbook of Medical-Surgical Nursing. 10th edition
The client experienced dyspnea. She reports “naglisud ko ug ginhawa.”
Breath sounds Absent Wheezing or hoarseness may signal blockage or inflammation in the lungs that may go along with cancer. Smeltzer, Suzanne C. Textbook of Medical-Surgical
The client has no adventitious breath sounds.
PATHOPHYSIOLOGY
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Genetic mutation occurs
Type IOccurs when one gene is omitted completely
Type IIOccurs when one amino acid is omitted, making a false DNA
Type IIIOccurs when an additional codon is added to the protein
Damage in DNA
Activation Repair
Failure of DNA repair
Modified proto-oncogene function
Deactivation of tumor suppressor genes
Activation of apoptosis
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Unregulated cell growth and differentiation
Unregulated cell growth and differentiation
Transformation of epithelial cell in the tracheobroncho airways
Carcinogens= air pollutants
Malignant cell
Accumulation of malignant cell = pulmonary epithelium transformed to adenocarcinoma
Transfer of wrong DNA to daughter cell
Transformation of proto-oncogenes to
oncogenes
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The adenocarcinoma is presented more peripherally as peripheral mass and nodules often metastasize.
Lung adenocarcinoma
If Treated: Radiation Therapy Chemotherapy
If Untreated:
Metastasis occurs
Cancer cells spread to nearby lymph nodes
and organs
Sign and symptom:Dyspnea
Alteration in organ function
Multiple organ failure
Death
Good Prognosis
DOCTOR’S ORDER
Date ordered Order Rationale RemarksJuly 2, 2009 Low salt, low fat diet. Low fat low salt diet
prevents increase in blood volume thus
decreasing the possibility of fluid in
the lungs.
Done
VS monitoring q4h To monitor vital signs so that any
discrepancies will be referred as follows.
Done
Complete Blood Count
It used to determine the quantity of each
type of blood cell in a given sample of
blood, often including the
amount of hemoglobin, the
hematocrit, and the proportions of
various white cells.
Done
Platelet Aggregation Test
Platelets are disk-shaped blood cells that are also called
thrombocytes. They play a major role in the blood-clotting
process. The platelet aggregation test is a measure of platelet
function. The platelet aggregation test uses a machine
called an aggregometer to
measure the cloudiness
(turbidity) of blood plasma.
Done
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Blood Test An analysis of a sample of blood,
especially for diagnostic or therapeutic purposes.
Done
Prothrombin time The prothrombin time test belongs to
a group of blood tests that assess the
clotting ability of blood. The test is also known as the
pro time or PT test. The blood is
collected in a tube that contains sodium citrate to prevent the clotting process from
starting before the test. The blood cells are separated from
the liquid part of blood (plasma). The PT test is performed
by adding the patient's plasma to a protein in the blood
(thromboplastin) that converts
prothrombin to thrombin. The
mixture is then kept in a warm water
bath at 37°C for one to two minutes. The
test is timed from the addition of the calcium chloride until the plasma
clots.
Done
Chest X- ray for Physical Assessment
A chest x ray is a procedure used to
evaluate organs and structures within the
Done
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chest for symptoms of disease. Chest x
rays include views of the lungs, heart, and small portions of the
gastrointestinal tract, thyroid gland and the bones of the chest area. The chest
x ray may be performed in a
physician's office or referred to an
outpatient radiology facility or hospital
radiology department.
Electrocardiogram The electrocardiogram
(as a paper trace or a TV monitor display)
shows the changes in the voltage,
detectable during the time course of
the heart beat, between pairs of
electrodes placed at certain points on the
skin.
Done
O2 Saturation at ER to record
This will determine whether the patient is receiving enough oxygen in the blood
and to determine whether or not the
patient is in respiratory distress
e.g hypoxia.
Done
Theopylline (Nuelin)Norvasc
Vitamins + Minerals (Centrum)
These medications help alleviate patient’s pain,
prevent complications and
help in the
Done
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curative/palliative process.
NPO status Ensuring NPO status will prevent
aspiration of fluids during surgical
procedures.
Done
For stat CTT insertion at 10pm
under sedation
A chest tube insertion is a
procedure to place a flexible, hollow
drainage tube into the chest in order to remove an abnormal
collection of air or fluid from the pleural space
(located between the inner and outer
lining of the lung). Chest tube insertions
are usually performed as an
emergency procedure. Chest tubes are used to
treat conditions that can cause the lung to
collapse, which occurs because
blood or air in the pleural space can
hamper the ability of a patient to breathe.
Done
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DIAGNOSTIC EXAM
COMPLETE BLOOD COUNT WITH PLATELET COUNT
Date ExamNormal
ValueRationale
Result of
Patient
Clinical
SignificanceNursing Responsibilities
July 2,
2009
Hemoglobin120– 160
g/dL
The test that
measures the
amount of
hemoglobin per
liter of blood
122 g/dL Normal 1. Discuss and explain the procedure and
purpose of the test.
2. Inform the patient that no fasting is needed.
3. Assess the patient for any factor that will
probably affect the results of the test.
4. Make sure patient is well hydrated.
Dehydration elevates the test results.
5. If patient is connected to IVF, make sure
that the blood is not taken from the arm
connected to the IVF. Hemodilution causes
false decrease of the test results.
HematocritM: 42-52%
F: 37-47%
The test
measures the
percentage of
RBC in the total
blood volume
35% Normal
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Date ExamNormal
ValueRationale
Result of
Patient
Clinical
SignificanceNursing Responsibilities
6. After the puncture, assess the site for
bleeding or bruising.
7. If patient is under treatment from an
infection, inform the patient that the test will
be repeated to monitor progress.
8. Any abnormality noted will be reported to
the physician.
WBC count 0.5-10
X10^9/L
The test
measures all
leukocytes
present in 1
cubic millimeter
of blood.
13.6 X
10^9/L
HIGH:
Conditions 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
ValueRationale
Result of
Patient
Clinical
SignificanceNursing Responsibilities
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
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Date ExamNormal
ValueRationale
Result of
Patient
Clinical
SignificanceNursing Responsibilities
Eosinophils 1 – 8%
Eosinophils
initiate allergic
responses and
act against
parasitic
infestation. The
test is use to
diagnose worm
infestation.
2% Normal
RBC count 4.0-5.0X
10^12/L
The test
measures the
circulating RBCs
in 1 cubic
millimeter of
blood.
4.73X
10^12/L
Normal
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Date ExamNormal
ValueRationale
Result of
Patient
Clinical
SignificanceNursing Responsibilities
Thrombocytes150- 300X
10^9/L
The test
measures the
amount of
platelets that are
important for
blood clotting.
290
X10^9/LNormal
Lymphocytes 20-40%
The test
meaures the
percentage of
the principal
component of
the body’s
immune system.
20% Normal
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PROTHROMBIN TME
Date ExamNormal
ValueRationale
Result of
Patient
Clinical
SignificanceNursing Responsibilities
July 2,
2009
Prothrombin
time
12-15
seconds
The
prothrombin
time is the time
it takes plasma
to clot after
addition of
tissue factor.
This measures
the quality of the
extrinsic
pathway (as well
as the common
pathway) of
coagulation.
12.4
secondsNormal
1. Discuss and explain the procedure and purpose of the test.
2. Assess the patient for any factor that will probably affect the results of the test.
3. Check to see if the patient is taking any medications that may affect test results. This precaution is particularly important if the patient is taking warfarin, because there are a number of medications that can interact with warfarin to increase or decrease the PT time.
4. After the procedure,there must be routine care of the area around the puncture mark. Apply moist warm compresses on the area around the puncture mark.
51 | P a g e
Date ExamNormal
ValueRationale
Result of
Patient
Clinical
SignificanceNursing Responsibilities
5.Apply pressure for a few seconds and the cover the wound with a bandage.
6. Inform the patient that there might be mild dizziness and the possibility of a bruise or swelling in the area where the blood was drawn.
International Normalized
Ratio0.8–1.2
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
Drug Study
Generic Name Theophylline
Brand Name Immediate-release liquids:
Accurbon, Aerolate, Asmalix, Bronkodyl, Elixomin, Elixophyllin, Lanophyllin,
Theolair Liquid
Immediate-release tablets and capsules:
Bronkodyl, Elixophyllin, Nuelin, Quibron T Dividose
Timed-release tablets
Quibron-T/SR, Theocron, Theolair-SR, T-Phyl, Uniphyl
Timed-release capsules:
Aerolate, Elixophyllin, Nuelin-SR, Slo-bid Gyrocaps, Theobid, Duracaps, Theocron, Theo-24
Classification Xanthine derivative; Pregnancy risk Category C
Indication and
Dosage
Oral theophylline for acute bronchospasm in patients not currently receiving theophylline
Adult nonsmokers and children older than age 16: 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
Children ages 9-16: 5 mg/kg P.O.; then 3 mg/kg q 4 hours for three doses. Maintenance dosage is 3 mg/kg q 6
hours.
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Children ages 6 months to 9 years: 5 mg/kg P.O.; then 4 mg/kg q 4 hours for three doses. Maintenance dosage is
4 mg/kg q 6 hours.
Parenteral theophylline for patients not currently receiving theophylline
Loading dose: 4.7 mg/kg I.V. slowly; then maintenance infusion.
Adult nonsmokers and children older than age 16: 0.55 mg/kg/hour I.V. for 12 hours; then 0.39 mg/kg/hour.
Children ages 9 to 16: 0.79 mg/kg/hour I.V. for 12 hours; then 0.63 mg/kg/hour.
Children ages 6 months to 9 years: 0.95 mg/kg/hour I.V. for 12 hours; then 0.79 mg/kg/hour.
Oral and parenteral theophylline for acute bronchospasm in patients currently receiving theophylline
Adults and children: ideally, dose is based on current theophylline level. Each 0.5 mg/kg I.V. or P.O. loading
dose will increase drug level by 1 mcg/ml. In emergencies, when theophylline level can’t be readily obtained,
some prescribers recommend a 2.5-mg/kg P.O. dose of rapidly absorbed form if patient develops no obvious
signs or symptoms of theophylline toxicity.
Chronic bronchospasm
Adults and children: initially, 16 mg/kg or 400 mg P.O. daily, whichever is less, given in three or four divided
doses at 6- to 8-hour intervals. Or, 12 mg/kg or 400 mg P.O. daily, whichever is less, in an extended-release
preparation given in two or three divided doses at 8- or 12-hour intervals. Dosage may be increased, as
tolerated, at 2- to 3-day intervals to the following maximums: adults and children older than age 16, 13 mg/kg
or 900 mg P.O. daily, whichever is less; children ages 12 to 16, 18 mg/kg P.O. daily; children ages 9 to 12, 20
mg/kg P.O daily; children younger than 9, 24 mg/kg P.O daily.
Mode of Action Inhibits Phosphodiesterase, the enzyme that degrades cAMP, resulting in relaxation of smooth muscle of the
bronchial airways and pulmonary blood vessels.
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Contraindication Contraindicated in patients hypersensitive to xanthine compounds (caffeine, theobromine) and in those with
active peptic ulcer or poorly controlled seizure disorders.
Drug
Interactions
Drug-drug. Adenosine: may decrease antiarrhythmic effect. Higher doses of adenosine may be needed.
Allopurinol, calcium channel blockers, cimetidine, disulfiram, influenza virus vaccine, interferon, macrolides,
methotrexate, mexiletine, oral contraceptives, quinolones: may decrease hepatic clearance of theophylline; may
increase theophylline level. Monitor level closely and adjust theophylline dose.
Barbiturates, ketoconazole, nicotine, phenytoin, rifamycins: may enhance metabolism and decrease
theophylline level; may increase phenytoin metabolism. Monitor patient for decreased therapeutic effect;
monitor levels and adjust dosage.
Carbamazepine, isoniazid, loop diuretics: may increase or decrease theophylline level. Monitor theophylline
level.
Carteorol, pindonol, propranolol, timolol: may act antagonistically, reducing the effects of one or both drugs;
may reduce elimination of theophylline. Monitor theophylline level and patient closely.
Ephedrine, other sympathomimetics: may exhibit synergistic toxicity with these drugs, predisposing patient to
arrhythmias. Monitor patient closely.
Lithium: may increase lithium excretion. Monitor patient closely.
Tetracyclines: may enhance the adverse effects of theophylline. Monitor patient closely.
Drug-herb. Cacao tree: may inhibit drug metabolism. Discourage use together.
Cayenne: may increase risk of drug toxicity. Advise patient to use together cautiously.
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Ephedra: may increase risk of adverse reactions. Discourage use together.
Guarana: may cause additive CNS and CV effects. Discourage use together.
Ipriflavone: may increase risk of drug toxicity. Advise patient to use together cautiously.
St. John’s wort: may decrease drug level. Discourage use together.
Drug-food. Any food: may cause accelerated drug release from extended-release products. Tell patient to take
extended-release products on an empty stomach,
Caffeine: may decrease hepatic clearance of drug and increase drug level. Monitor patient for toxicity.
Drug-lifestyle. Smoking: may increase elimination of drug, increasing dosage requirements. Monitor drug
response and level.
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,
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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, 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.
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Generic Name amlodipine besylate 5 mg , 1 tab OD ac
Brand Name Norvasc
Classification calcium channel blocker; Pregnancy risk category C
Indication and
Dosage
Chronic stable angina, vasospastic angina
(Prinzmetal or variant angina)
Adults: Initially, 5 to 10 mg P.O. daily. Most patients need 10 mg daily
Elderly patients: Initially, 5 mg P.O. daily.
Hypertension
Adults: Initially, 2.5 to 5 mg P.O. daily. Dosage adjusted according to patient response and tolerance.
Maximum daily dose is 10 mg.
Elderly patients: Initially, 2.5 mg P.O. daily.
Mode of Action Inhibits calcium ion influx across cardiac and smooth-muscle cells, dilates coronary arteries and arterioles, and
decreases blood pressure and myocardial oxygen demand.
Contraindication Contraindicated in patients hypersensitive to drug.
Drug
Interactions
None reported.
Side/ Adverse
Effects
CNS: headache, somnolence, fatigue, dizziness, light-headedness, paresthesia.
CV: edema, flushing, palpitations.
GI: nausea, abdominal pain.
GU: sexual difficulties.
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Musculoskeletal: muscle pain.
Respiratory: dyspnea.
Skin: rash, pruritus.
Nursing
Responsibilities
ALERT: Monitor patient carefully. Some patients, especially those with severe obstructive coronary artery
disease, have developed increased frequency, duration, or severity of angina or acute MI after initiation of
calcium channel blocker therapy or at time of dosage increase.
Monitor blood pressure frequently during initiation of therapy. Because drug induced vasodilation has a
gradual onset, acute hypotension is rare.
Notify the physician if signs of heart failure occur, such as swelling of hands and feet or shortness of breath.
ALERT: Abrupt withdrawal of drug may increase frequency and duration of chest pain. Taper dose gradually
under medical supervision.
Look alike-sound alike: Don’t confuse amlodipine with amiloride.
Patient Teaching
Caution patient to continue taking drug, even when feeling better.
Tell patient S.L. nitroglycerin may be taken as needed when angina symptoms are acute. If patient continues
nitrate therapy during adjustment of amlodipine dosage, urge continued compliance.
59 | P a g e
Generic Name Multivitamins + minerals 1 tab OD ac
Brand Name Centrum®
Classification Vitamins &/or Minerals
Indication and
Dosage
Complete multivitamin & mineral formula.
Dosage: 1 tab/day
Mode of Action Vitamins:
1) Vit A:
Helps form and maintain healthy skin, eyes, teeth, gums, hair, mucous membranes and glands
Necessary for night and color vision
Important for resisting infectious diseases
Important for normal growth in children
Involved in fat metabolism
2) Vit. E
a) Necessary for the formation of normal red blood cells, muscle, and tissue
b) Necessary for immune functions
c) Protects fat in tissues from oxidation
d) Helps protect cells from free radical damage
3) Vit. C
Helps bind cells
Strengthens blood vessel walls
Essential for healthy teeth, gums and bones
60 | P a g e
Important in the formation of the protein collagen, which helps support the body structures such as skin,
bones and tendons
Helps in the absorption of iron from supplements and vegetables
Important for immune functions
Necessary for the formation of some neurotransmitters
Necessary for wound repair
4) Vit. B1
Aids in energy utilization from food by promoting proper carbohydrate metabolism
Necessary for proper functioning of the nervous system and muscles, including the heart muscles
5) Vit. B2
Aids in energy utilization from food
Needed for vision
Helps in red blood cell formation and nervous system functioning
Essential for the metabolism of vitamin B6, niacin, folic acid and vitamin K
6) Vit. B6
Important in protein and amino acid metabolism
Necessary for proper function of the nervous and immune systems
Necessary for red blood cell formation
Necessary for hormone synthesis
7) Vit. B12
Helps form red blood cells and build vital genetic material (nucleic acids) for the cell nucleus
Necessary for reducing the risk of certain forms of anemia
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Aids in the function of all body cells, especially nerve, red blood and brain cells
8) Vit. D
Helps prevent and cure rickets in children
Necessary for strong bones and normal growth in children
Helps the body use calcium and phosphorus properly
May help to maintain healthy bones
Necessary for calcium absorption
9) Vit K
Necessary for normal blood clotting
Important for bone health
10) Niacinamide
Present in all cells in the body helps convert food into energy; involved in fat, protein, and carbohydrate
metabolism
Aids in nervous system function
11) Folic acid
Adequate amounts of this B Vitamin (folic acid) as part of a healthy diet, can help reduce the risk of birth
defects of the brain and spine
Helps maintain normal, healthy function of the intestinal tract
Necessary for amino acid metabolism and the formation of nucleic acids that form DNA
Necessary for normal growth and development
Necessary for red blood cell formation
12) Biotin
62 | P a g e
Necessary for formation of fatty acids
Necessary for production of energy from glucose
Required for metabolism of several amino acids
Assists in utilization of B-vitamins such as niacin
13) Pantothenic acid
Involved in converting carbohydrates, fats and proteins into energy
Necessary for the formation of nerve-regulating substances and hormones
Helps in normal growth and development
Minerals:
14) Phosphorus
Helps build and maintain teeth and bones
Essential in muscle and nerve functions and in the release of energy
Enhances use of other nutrients
Necessary in formation of DNA and cell membranes
Helps bring phosphorus levels to normal in people with diabetes, alcoholism, kidney disease, and those who
chronically take certain types of antacids that bind phosphorus
15) Iodine
Essential for formation of thyroid hormone thyroxin which governs metabolism and growth
Essential for reproduction
Involved in conversion of beta carotene to Vitamin A
Involved in synthesis of protein and cholesterol and in the absorption of carbohydrates
16) Iron
Essential part of hemoglobin
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Part of certain essential metabolic enzymes
Vitamin C enhances Iron absorption
17) Magnesium
Maintains proper levels of calcium and potassium
Helps bones absorb phosphorus
Critical component of many vital enzyme reactions
Regulates heartbeat, muscle contractions and nerve transmissions
Essential component of soft tissues, body fluid and bones
18) Copper
Part of proteins and enzymes involved in brain and red cell function
Involved in iron metabolism, bone health and protein synthesis
Plays a role in skin, hair and eye pigmentation
19) Zinc
Zinc may be an important factor in helping to maintain a healthy immune system
Critical component of enzymes involved in most major metabolic pathways
Part of several vital hormones including insulin
Involved in ability to taste
Aids in wound repair
Involved in protein metabolism
Important for night vision
20) Calcium
Helps build and maintain strong teeth and bones
Helps to reduce risk of osteoporosis
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Aids in clotting of blood
Functions in normal muscle contraction and helps nerves work normally
Regulates heartbeat
May help reduce the risk of colon cancer
May prove valuable in preventing and treating hypertensive disorders associated with pregnancy
21) Chromium
Necessary for normal carbohydrate, protein and fat metabolism
22) Molybdenum
Important for normal cell function
Important to maintain normal growth
Component of enzymes needed in metabolism
23) Selenium
Complements vitamin E to help fight cell damage from oxidation
Needed for proper immune system response
Plays a role in many antioxidant enzymes
Helps prevent Keshan disease
Necessary for normal growth and development
Necessary for use of iodine in metabolism of thyroid hormones
24) Nickel
Enhances the body’s use of iron
Maintains the structure of nucleic acid
Fat metabolism
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25) Tin
Necessary for normal growth
Cell metabolism
Maintains structure of nucleic acid
26) Silicon
May be necessary for normal cartilage, collagen and bone formation
27) Vanadium
Pharmacological studies in animals suggest that vanadium may be involved in hormone, glucose, fat, bone and
tooth metabolism as well as reproduction and growth
28) Manganese
Necessary for normal growth and development, reproduction and cell function
Involved in metabolism of carbohydrates
29) Potassium
It is part of a number of metabolic actions, especially those that involve release of energy
Needed for muscle growth
Regulates heartbeat and muscle contraction
Helps regulate blood pressure
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 conditions, especially if any of the following
applies:
if patient is pregnant, planning to become pregnant, or are breast-
66 | P a g e
feeding
if patient is taking any prescription or nonprescription medicine, herbal
preparation, or dietary supplement
if patient has anemia, liver problems, or metabolism problems
Drug
Interactions
calcium increases toxicity of beta-methyldigoxin
calcium reduces effect of ciprofloxacin
calcium reduces effect of ciprofloxacin hydrochloride
calcium reduces effect of ciprofloxacin lactate
calcium increases toxicity of deslanoside
calcium increases toxicity of digitaline
calcium increases toxicity of digitalis
calcium increases toxicity of digitoxin
calcium increases toxicity of digitoxinum
calcium increases toxicity of digoxin
calcium increases toxicity of digoxinum
calcium increases toxicity of medigoxin
calcium increases toxicity of methyl digoxin
calcium increases toxicity of methyldigoxin
calcium increases toxicity of metildigoxin
calcium increases toxicity of proscillaridin
iron increases toxicity of dimercaprol
potassium causes additive toxicity with amiloride
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potassium causes additive toxicity with amiloride hydrochloride
potassium causes additive toxicity with canrenoate potassium
potassium causes additive toxicity with canrenone
potassium causes additive toxicity with eplerenone
potassium causes additive toxicity with potassium canrenoate
potassium causes additive toxicity with spironolactone
potassium causes additive toxicity with triamterene
Side/ Adverse
Effects
vit A
Doses in excess of 8,000 IU a day taken by pregnant women may cause an increased risk in birth defects
vit E
none reported
vit C
Doses in excess of 2,000 mg/day can cause diarrhea or transient gastroenteritis
vit B 1
No reported adverse effects at doses studied up to approximately 50 mg / day
vit B 2
No reported adverse effects in studies with doses up to 200 mg/day
vit B 6
none reported
vit B 12
No risk of adverse effects from supplemental vitamin B12 to the general population at doses that are several
folds higher than the current RDA for vitamin B12.
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vit D
none reported
vit K
none reported
niacinamide
none reported
folic acid
none reported
biotin
No adverse side effects have been found at doses as high as 10 mg a day
Toxicity has not been reported in patients treated with daily doses up to 200 mg orally
pantothenic acid
No evidence of toxicity associated with intake of Pantothenic Acid
Minerals:
phosphorus
Excess phosphorus in relation to calcium intake can lower blood calcium levels
iodine
none reported
Iron
Accidental overdose of iron-containing products is a leading cause of fatal poisoning in children under 6 years
old
Magnesium
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Doses above 700 mg per day can cause diarrhea
Those with impaired kidneys can easily become overloaded, ultimately leading to respiratory depression and
coma
Copper
None reported
Zinc
Doses in excess of 60 mg can cause gastrointestinal intolerance and can interfere with copper status,
negatively affect immune responses and lower high density lipoproteins
Calcium
None reported
Chromium
None reported
Molybdenum
None reported
Selenium
None reported
Nickel
Doses in excess of 250 mg can cause adverse effects such as gastrointestinal irritation or exacerbation of
copper or iron deficiencies
Tin
50 mg/day of tin can cause Nausea, vomiting and diarrhea
Silicon
70 | P a g e
None reported
Vanadium
Doses of 4.5 mg a day may cause cramps and diarrhea
Manganese
None reported
Potassium
Excessive use can cause weakness, paralysis, abdominal distention, and a very rapid heart beat
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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SURGICAL PROCEDURE
Surgical Memo
Date of Operation: July 2, 2009
Time of Operation:
Age: 65 years old
Diagnosis: Left Massive Pleural Effusion secondary to Lung Cancer
Operation Performed: Chest Tube Thoracostomy
Type of Anesthesia: General
Complete Name of
Surgeon:
Dr. Geoffrey Lei
Anesthesiologist Dr. Barinaga
Student Nurse: Ana Patricia Dujali
Procedural Report
A. Definition of Chest Tube Thoracostomy
A chest tube thoracostomy involves the surgical placement of a hollow, flexible drainage tube into the chest. This procedure is also referred to as chest drainage tube insertion, insertion of tube into chest; tube insertion. Chest tubes are used to treat conditions that can cause the lung to collapse, such as air leaks from the lung into the chest (pneumothorax), bleeding into the chest (hemothorax), after surgery or trauma in the chest, and lung abscesses or pus in the chest (empyema).
A. Nursing Responsibilities
b.1 PRE-OPERATIVE PHASE
Nursing Responsibilities: Secure the informed consent and take note of the important things
to remember:
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1. The surgeon must provide a clear explanation of the surgical procedure to be done.
2. The nurse asks the patient to sign the consent form.3. The nurse may serve as the witness when the client makes
the signature.6. If the patient is unconscious or incompetent, permission
must be taken from a family member or legal guardian.8. Patient should not be forced to sign an operative permit.
Assess the nutritional status of the patient to note any contraindications with the surgical procedure.
Assess for the previous medication use. A medication history is obtained from each patient because of the possibility of drug interactions
Assess the patient for pneumothorax, hemothorax, presence of respiratory diseases.
Obtain a chest x-ray to evaluate the extent of lung collapse or amount of bleeding in pleural space. Other means of localization of pleural fluid include ultrasound and/or fluoroscospic localization
Teach cognitive coping strategies such as imagery, distraction and optimistic self-recitation to reduce fear and anxiety
Explain the activities that may occur inside the operating room to reduce anxiety
Tell the patient to expect a needle prick and a sensation of slight pressure during infiltration anesthesia.
Inform the patient on the following to impart knowledge on the part of the patient and to avoid delay in surgery due to incompliance:o Scheduled date and time of the surgery and where to
reporto What to bring such as insurance card, list of
medications and allergieso What to leave at home such as jewelry, watch,
medications and contact lenseso What to wear which is loose-fitting, comfortable
clothes and flat shoeso To take nothing by mouth for six to 12 hours before
the surgery. Request pain medications as needed to relief the patient from pain
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Acquire and document patient’s vital signs for baseline data and maintain the preoperative record
Transport the patient to the presurgical area to prepare the patient for surgery
Attend to the family needs to reduce the anxiety felt by the family Make sure that preoperative checklist which contains the
following is accomplished:o Lab exam results ino OR services form accomplishedo Patient is scheduled in ORo Anesthesiologist informedo Medicines ino Blood Typed and Matchedo Field of Operation preparedo Sponged or bathedo Diet instruction giveno Enema giveno Make-up and nail polish removedo Jewelry and denture removedo Oral hygiene giveno Patient changed into patient’s gowno Indwelling catheter insertedo Pre-op meds given o Medicine for OR in
b.2 INTRAOPERATIVE PHASE
Nursing Responsibilities
Preparation of the patient; surgical position: o Position the patient appropriately. If he has a pneumothorax,
place him in high Fowler’s position, semi-Fowler’s position, or the supine position. The physician will insert the tube in the anterior chest at the midclavicular line in the second to third intercostals space. If the patient has a hemothorax, have him lean over the overbed table or straddle a chair with his arms dangling over the back. The physician will insert the tube in the anterior chest at the midaxillary line in the fourth to sixth intercostals space. For either pneumothorax or hemothorax, the patient may lie on his unaffected side with arms extended over his head.
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Skin preparation and draping:
o The field around the area of the anterior chest is draped with folded towels exposing only the site to be incised.
Circulating nurse:o Manages the operating roomo Protects patient’s safety and health by monitoring the
activities of the surgical teamo Checks and verifies the consent formo Ensures fire safety precautions, cleanliness, proper
temperature, humidity and lighting of the operating roomo Monitors safe functioning of the equipmentso Coordinates with the surgical/perioperative team and
monitors aseptic practiceso Documents operating room surgical activitieso Count all needles, sponges and instruments together
with the scrub nurse
For registered nurse first assist:o Suturing and handling of tissueso Providing exposure at the operative field
For the scrub nurse:o Setting up sterile tableso Assisting the surgeon and assistant surgeon, taking
care of tissue specimenso Count all needles, sponges and instruments together
with the circulating nurseo Cutting and dissecting needles should be kept
separately from other instruments and demands careful handling at all times
Type of anesthesia used: The anesthesiologist asks the patient about medical history and will be the one to determine the right anesthesia for the patient. The most common forms of anesthesia are general, local, and monitored anesthesia. With a general anesthetic, patient will be asleep during the surgical procedure. With a local anesthetic,
75 | P a g e
patient will be alert during the surgery, and only the incision location will be anesthetized. With monitored anesthesia care or MAC, patient will be given medications to help him relax, and the incision location will be anesthetized.
Materials:
Chest tube with or without trocar; OR Fuhrman catheter
Chest tube suction unit, tubing, wall suction hookup
Chest tube tray to include scalpel blade and handle, large Kelly clamps, needle driver,
scissors
Packet of 0 or 1.0 silk suture on a curved needle
Tape, gauze
2% lidocaine with epinephrine, 20 cc syringe, 23-gauge needle for infiltration
Sterile prep solution; mask, gown and gloves
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After positioning the patient and doing skin preparation, place the chest tube tray on the overbed table. Open it using sterile technique.
The physician puts on sterile gloves and prepares the insertion site by cleaning the area with antiseptic solution.
Wipe the rubber stopper of the lidocaine vial with an alcohol pad. Then, invert the bottle and hold it for the physician to withdraw the anesthetic.
Immediately after the drainage system is connected, instruct the patient to take a deep breath, hold it momentarily, and slowly exhale to assist drainage of the pleural space and lung expansion.
After the physician anesthetizes the site, he make a small incision and inserts the chest tube. Next, he immediately connects the tube to the drainage system or momentarily clamps the tube close to the patient’s chest until he can connect it to the drainage system. And then, he secures the tube to the skin of the patient with a suture.
As the physician inserting the chest tube, reassure the patient and assist the physician as necessary.
Open the packages containing the petroleum gauze. 4 x4 “drain dressings, and gauze pads. Then place the petroleum gauze pads, and two 4 x 4” drain dressings around the incision site, one from the top and the other from the bottom. Place several 4 x 4 “gauze pads on top of the drain dressings.. Tape the dressings, covering them completely to form an occlusive dressing.
Securely tape the test tube to the patient’s chest distal to the insertion site to help prevent accidental tube dislodgement.
Securely tape the junction of the chest tube and the drainage tube to prevent their separation.
b.3 POST OPERATIVE PHASE
Observe the drainage system for blood or air. Observe for fluctuation in the tube on respiration.
Secure a follow-up chest x-ray to confirm correct tube replacement and reexpansion of the lung.
Assess for bleeding, infection, leakage of air and fluid around the tube. Fluctuations of fluid in the tubing will stop when the lung has reexpanded, the tubing is obstructed by blood clots or fibrin, a dependent loop develops, and when suction motor or wall suction is not operating properly.
Take the patient’s vital signs every 15 minutes for 1 hour, then as his condition indicates. Auscultate his lungs at least every 4 hours following the procedure to assess air exchange in the affected lung. Diminish or absent breath sounds indicate that the lung has not reexpanded.
Monitor and record the drainage in the drainage collection chamber.
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Treatment:
Strict compliance on Doctor’s order. Regular and daily hygiene are physically and emotionally therapeutic; aids in
restoring arm function and provide a sense of normalcy to the patient.
Health Teachings: Inform the patient about the importance of complying with the prescribed
medication. Emphasize the proper dosage of the medications taken. Educate the client about the importance of proper nutrition. Encourage the client to have the prescribed diet for his condition.
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NURSING THEORIES
1) Florence Nightingale’s Environmental Adaptation Theory:
It is known that Florence Nightingale is recognized as founder of modern-
day nursing. Her environmental model is based on the idea that the thrust for
healing lies within the individual human being and the focal point of care is to place
the individual in an environment that is supportive to that healing process. Her
famous principles speak to areas that require the attention of the nurse. These are
cleanliness, ventilation, warming, light, noise, variety, nutrition, “chattering hopes
and advices,” and observation of the sick.
Upon looking at our patient, and knowing her diagnosis, it can be clearly
stated that Nightingale’s Environmental Adaptation theory can be applied. Having
lung cancer, the patient must obviously not be placed in an area which can make her
condition worse, but rather, in a place which could promote faster healing. Areas
with the absence of smoke, or those that are properly ventilated would definitely
support and encourage safe breathing. Moreover, she must be situated in an area
with limited noise to promote rest and sleep, which allows her to regain her
strength instantaneously. Also, she must follow a balanced diet to achieve proper
nourishment, and again, add up to her course of therapy. Lastly, the patient’s
support group must at least stay with her during her recovery process, to possibly
give constant support and advices for her to be able to attain maximum care, and
lead to her improvement and healing.
2) Virginia Henderson’s Theory
Virginia Henderson clearly delineated nursing from medicine in her
statement that the unique function of the nurse is to assist the individual, sick or
well, in the performance of those activities contributing to health or its recovery
that she would perform unaided if she had a necessary strength, will, or knowledge
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and to do this in such a way as to help her gain independence as rapidly as possible.
She proposed 14 components of basic nursing care which are as follows: the
individual can (1) breathe normally, (2) eat and drink adequately, (3) eliminate
body wastes, (4) move and maintain desirable postures, (5) sleep and rest, (6) select
suitable clothes, (7) maintain body temperature within the normal range by
adjusting clothing and modifying the environment, (8) keep the body clean and well-
groomed and protect the integument, (9) avoid dangers in the environment and
avoid injuring others, (10) communicate with others in expressing emotions, needs,
fears and opinions, (11) worship according to one's faith, (12) work in such a way
that there is a sense of accomplishment, (13) play or participate in various forms of
recreation and (14) learn, discover, or satisfy the curiosity of the patient that leads
to normal development and health and use the available health facilities.
In the application of Henderson’s theory in our patient, the interventions
performed by the nurse should be also directed in assisting the patient to achieve
independence. Fortunately, in the patient’s current status she is trying to become
independent. Although the patient can eat and drink adequately, sleep and rest,
communicate her feelings and needs, the patient still cannot work, learn, discover
and satisfy her curiosity, and even eliminate body wastes effectively, nor can she
breathe normally because of her condition. This is where nursing care comes in. For
her to be able to breathe normally, proper positioning on moderate high back rest
was executed because this position promotes maximum lung expansion, which
provides optimum ventilation. Elimination of body wastes is monitored properly
with the help of her significant others, with the use of measuring cups, and with the
use of the chest tube attached at her left 6th and 7th intercostal area to drain the
pleural fluid. Providing comfortable and quiet environment to lessen the stressors of
the patient and hasten the recovery process. Choosing appropriate clothing for the
patient for comfort and decrease the risk of impaired skin integrity. Keeping the
body clean and well groomed and lessening the risk of injury and infection. All of
these are implemented by the student nurse with the cooperation significant others
to provide effective and quality care.
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3) Dorothea Orem's Self-Care Deficit Theory
Dorothea E. Orem’s general theory of nursing is made up of the three
interrelated theories of self-care, self-care deficit, and nursing systems. A peripheral
concept, basic conditioning factors, applies to all of the theories. The major concepts
of self-care are self-care, self-care agency, self-care requisites (universal,
developmental, and health deviation), and therapeutic self-care demand. In this
discussion, we will be focusing particularly on her Self-care deficit theory. To
understand this specific theory of Orem, there is a need to know what self-care is.
Self-care is the performance or practice of activities that individuals initiate and
perform on their own behalf to maintain life, health and well-being. A deficit
delineates when nursing is needed. Nursing is required when a person is incapable
of or limited in the provision of continuous effective self-care. She conceptualized
three nursing systems: 1. Wholly Compensatory: when the nurse is expected to
accomplish all the patient’s therapeutic self-care or to compensate for the patient’s
inability to engage in self-care or when the patient needs continuous guidance in
self-care; 2. Partially Compensatory: when both nurse and patient engage in meeting
self care needs; 3. Supportive Elective: the system that requires assistance in
decision making, behavior control and acquisition of knowledge and skills. Orem
enumerated five methods of helping which are as follows: acting or doing for
another, guiding and directing, providing physical or psychological support,
providing and maintaining an environment that supports personal development,
and teaching.
Mrs. Arbotante is clearly classified to be in the system of partially
compensatory. Since she can do some of the basic daily living activities such as
eating and drinking, and taking her medications, she shows to be somehow
independent. However, some activities such as rising and walking to the comfort
room either to urinate or defecate, or to take a bath, she still needs some
supervision and assistance. The student nurses are expected to provide care, along
with her significant others, to help the patient accomplish her needs, and eventually
help her to maintain health, well-being and life,. The theory was applied by utilizing
the five said methods of helping. First, acting or doing for the client was
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demonstrated by helping and assisting the client to her trip to the comfort room,
and administration of medications. Next, teaching, guiding and directing was done
to the family because of their willingness to help the client. They were given health
teachings on how to lessen the risk of infection and maintain the integrity of the
patient’s skin by practicing proper general hygiene and changing the position every
two hours. Also, the significant others are instructed to place the patient in
Moderate High Back Rest to promote favorable maximum lung expansion, and
enhance breathing ability. Physical support was provided by being readily available
to client and being able to adhere to the patient’s needs. Although the students
weren’t able to make the client achieve an overall personal development, they were
at least, able to help the client improve her post-op status, as evidenced by the
client’s improvement on her ability to ambulate. Also, they were successful in
providing a clean, cool, and quiet therapeutic environment where privacy is
considered for the preservation of the client’s integrity.
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NURSING CARE PLANPatient’s Name: Beachin’ Barato Age: 65 years oldChief Complaint: Difficulty of Breathing Attending Physician: Dr. Allan P. ArreolaGender: Female Shift: 3-11Diagnosis: Massive pleural effusion secondary to lung cancer. Date: July 2, 2009Room No.: 4C 444 to 244
Date and
Time
Cues Nursing Diagnosis Need(s) Objective(s) of care
Interventions Evaluation
July 3,
2009at
5:00pm
Subjective cues:
Verbalized difficulty in breathing.
Objective cues:
-Rapid breathing
-Respiratory rate: 23
cycles per minute
- O2
saturation of 65%
Impaired gas exchange related to disease process as evidenced by dyspnea.
(R) The presence of pleural fluid (a complication of
lung cancer wherein pleural fluid collects in the pleural space as a result of irritation or obstruction of the venous drainage by the
tumor), may hinder adequate lung expansion, and it causes the pleural membranes (essential for
diffusion of gases) to compress thus affecting
gas exchange.
ACTIVITY
EXERCISE
Within 3 hours of nursing care, the
patient will experience
improved gas exchanged as evidenced by:
a. Improved oxygenation (within
88%-100% O2
saturation) and
absence of respiratory
distress.b. Statement
of acceptable dyspnea.
c. Participatio
Independent:
Monitor vital signs.(R)To evaluate degree
of compromise.
Assess lung sounds, respiratory rate and
effort and use of accessory muscles. (R)
Respiratory rate less than 12 or more than 24 or use of accessory
muscles indicate distress. Diminished lung sounds indicate
possible poor air movement and
impaired gas exchange.
Observe skin and mucous membranes
for cyanosis. (R)
July 3, 2009 at 7:30pm
GOAL PARTIALLY MET.
Within three hours of nursing care, the
patient stated acceptable dyspnea. “Nakakahinga na ako ng mas maayos kaysa kanina.” In addition,
the patient participated in treatment regimen,
such as breathing exercises.
However, the patient still has respiratory distress and has 02
saturation by 7:30pm of only 73%.
Source:William, L. Hopper, P. (2007) Understanding
Medical Surgical Nursing: Third Edition.
Philadelphia: F. A Davis.
n in treatment regimen
(breathing exercises) within the
level of ability.
Cyanosis indicates poor oxygenation. Oral
mucous membrane cyanosis indicates serious hypoxia.
Monitor for confusion or changes in mental
status. (R) A change in mental status indicates impaired gas exchange.
Elevate head of bed or help the patient lean on
over bed table. (R) Upright position helps
promote lung expansion.
Encourage adequate rest and limit activities within client’s level of tolerance. Promote a
calm and restful environment. (R) Helps
limit oxygen needs/consumption.
Dependent:
Monitor for ABG prn.(R) PaO2 < 80 mmHg, PaCO2 > 45mmHg or SaO2 < may indicate
impaired gas exchange.
Administer supplemental oxygen
as ordered by the physician. (R)
Supplemental oxygen decreases hypoxia.
Administer medications as needed. (R) To treat underlying
conditions.
July 3,
2009 at
5pm
Subjective:“Ayaw i- taas ang ulohan nako, kay
naga-sakit ang akoang
dughan.”
Objective:
-Covers/Protects the painful area
-Resistance when it
comes to lifting the head part.
-Restricted movements.
-Pain scale of 6 out of 10.
Acute pain related to chest tube thoracostomy procedure as evidenced
by guarded and expressive behaviour.
(R) The effect of anaesthesia can be
diminished after the patient has been fully
awaked and conscious. The hole made by the incision
and insertion of chest tube can be painful, as
movements often cause tension and “pull” to the tube, thus the perceived
pain.
Source: William, L. Hopper, P. (2007) Understanding
Medical Surgical Nursing: Third Edition.
Philadelphia: F. A Davis.
COGNITIVE
PERCEPTUAL
Within 8 hours of nursing care, the
patient will:
a. State that her pain is
relieved (rating of 3-5 out of 10
in pain scale).
b. Verbalize methods
that provided
relief.
Independent:
Assess pain level q4h and prn. (R) Good
assessment must guide treatment.
Assess sedation and respiratory status
frequently. (R) Opioids are given carefully because they may
reduce respiratory rate and cough reflex, which
is vital to achieve normal breathing
pattern and clearing the airway.
Include nonpharmacological pain interventions
(such as distraction and relaxation). (R) It will help pain control
and reduce the need for opioids.
Dependent:Administer analgesics
as ordered, on an around- the- clock basis, via a patient-
controlled pump, for the first few days of
surgery. (R) The patient
July 3, 2009 at 7:30pm
GOAL MET.
The patient’s pain was relieved as evidenced
by pain scale of 4 out of 10. And the patient verbalized methods that provided relief
such as the pain medications given,
distraction techniques by constantly talking to
significant others.
who is pain free will be better able to
participate in care and take measures to
prevent complications such as coughing and
ambulating.
July 3,
2009at
5pm
Objective:
Post-op status:
Chest tube attached to
patient.
Risk for infection related to bypass of normal respiratory defense
mechanism.
(R) Patients diagnosed with cancer are often immunocompromised
which might be due to the diagnostic/palliative/curative procedures they have undergone. Such patients are at risk for infection,
which might be systemic, and most especially to
patients who have a portal of entry (for this instance
the tubing) which might be an pathway for
microorganisms to bypass normal defense
mechanism by the body, and directly enter the
body.
Source:William, L. Hopper, P. (2007) Understanding
Medical Surgical Nursing: Third Edition.
Philadelphia: F. A Davis.
HEALTH
PERCEPTION
HEALTH
MANAGEMENT
After 5 hours of nursing care, the
patient will:
a. Be free of infection as evidenced
by Temperatu
re, Blood Pressure
within normal
limits and absence of
complications (such as
redness and
swelling at the incision
site).
Independent:
Use good- handwashing technique. (R)
Handwashing is important in preventing
infections.
Monitor and report signs and symptoms of
infection: fever, increased respiratory
rate. (R) Early recognition and
treatment of infection enhances outcomes.
Palpate around the insertion sites for
crepitus. (R) Crepitus is associated with gas
gangrene, rubbing of bone fragments, or
crackles of a consolidated area of the
lung.
Check all tubing for kinds, breaks, or
broken connections. Verify that all
connections are securely taped.
(R) Microorganisms may infiltrate if there
July 3, 2009 at 10pm.
GOAL MET.
After rendering 5 hours of nursing care the
patient has a temperature of 36.5
degrees Celsius and a BP of 120/70. The
patient’s incision site is also free of redness
and swelling.
are any breaks in the connection.
Verify that the drainage system is
below level of patient’s chest at all times. (R) This will allow proper
drainage of pleural fluid.
Check collection chamber q8h or as
ordered for blood. (R) (R) Checking the
collection chamber allows the physician to monitor the output of
pleural fluid, making it sure that the fluid is just enough for the lungs to
not collapse.
Instruct client/ Significant others to
protect the integrity of the skin/ insertion
sites. (R) Protecting the integrity of the skin
helps prevent infection at the incision site.
Dependent:
Administer antibiotics prn. (R) Administering
antibiotics helps treat microorganisms that
are suspected to cause infection and/or
complications to the patient.
July 3,
2009 at
5:30pm
Subjective:“Although ganoon na
nga ang sitwasyon,
sana lang nga gumaling ako.
Yan ang ipinagdarasal ko every day.”
Objective:
-Patient attentive to instructions given by the
doctor.
-Family members are
faithful to medication
regimen and constantly
attending to client’s needs
such as ambulating, feeding the patient, and
also providing comfort.
Readiness for enhanced family coping related to
needs(physical/ psychological) of the
patient met as evidenced by patient having a positive approach
towards disease, and family members open to treatment programs and
support groups.
(R) The fact that individual needs are being sufficiently gratified and
adaptive tasks are effectively addressed and the surfacing of enabling self- actualizations are
met.
Source: Doenges, M. Moorhouse M. F. Geissler- Murr, A. (2004). Nurse’s
Pocket Guide: Ninth Edition. Philadelhia: F. A
Davis.
COPINGSTRESS
TOLERANCE
PATTERN
After 2 days of nursing care ( at July 4, 2009) the
patient will:
a. Express willingness to look at
own role in the family’s
growth.b. Verbalize
tasks leading to
change.c. Report
feelings of self-
confidence and
satisfaction with
progress being made.
Independent:
Observe communication
patterns of family. Listen to family’s
expression of hope, planning, and effect of
disease on relationship/s or life.(R) To assess situation and to observe family’s behaviour and attitude
towards an illness.
Note client’s expressions.
E.g Life has more meaning to me since this has occurred).
(R) To identify changes in values.
Provide time to talk with family.(R) To
discuss their view of the situation.
Discuss importance of open communication. (R) To assist family to
strengthen potential for growth.
Assist family members to support the client in
July 4, 2009 at 6:30pm.
GOAL PARTIALLY MET.
After 2 days of nursing care the patient
expressed willingness to look at own role in
the family’s growth. For this case, the disease. She said that as much
as possible, her potential as human
being will not be hampered by the
disease and her family will go on with their
lives as usual. She also verbalized: “Okay
naman ang mga tambal na ginahatag sa akoa. Nafeel pud nako na
murag makaginhawa na ko ug tarong pagkatapos sa
operasyon.”However, the patient did not recognize any
tasks leading to change in attitude or
behaviour.
meeting own needs within ability or
constraints of the illness/situation. (R)
This promotes independence, and at
the same time help them learn ways of assisting the client.
July 3,
2009at
5:30pm
Subjective:
“Dili ko kalihok ug
mayo. Nahadlok
man gud ko basig
matanggal.”
Objective:
- Inability to turn/ move to lateral
position when
lying in bed.
- Needs assistance when sitting down.
Impaired physical mobility related to
discomfort at surgical site and disease process.
(R) Cancer is a disease that often affects person’s
mobility due to fatigue and imbalance in nutritional intake (which might be due to medications or chemotherapy). The
incision site after chest tube insertion is not closed,
for the tube to be detached. This might cause
friction between the surface of the skin and the
tube which might cause discomfort and restrict
movement.
Sources:Berman. Snyder. Kozier.
Erb. (2007). Fundamentals of Nursing: eighth edition.
Pearson Prentice hall. William, L. Hopper, P. (2007) Understanding
Medical Surgical Nursing: Third Edition.
Philadelphia: F. A Davis.
ACTIVITY
EXERCISE
Within the 2-day duty the patient
will:
a. Verbalize understand
ing of situation or risk factors
and individual treatment regimen
and safety measures.
b. Demonstrate
techniques that enable resumption of activities.
c. Maintain skin
integrity as evidenced by absence of swelling,
redness, and pus
formation at the
surgical site.
Independent:
Determine degree of immobility. (R) to assess functional
ability.
Observe movement when client is unaware of observation. (R) To
note any incongruencies with reports of abilities.
Support affected body part. (R) To maintain position of function.
Perform range of motion exercises,
passively at first, then actively when the
patient is able. (R) This helps prevent
contracture of the arm and shoulder on the
affected site.
Assist patient to ambulate as tolerated
on first day prn.(R) Ambulation helps
maintain mobility and prevents postoperative
complications.
July 4, 2009 at 6:30pm.
GOAL MET.
Within the 2- day duty the patient verbalized understanding of the
situation and risk factors and also
individual treatment. “Pwede man ko
mulihok, pero dapat tan-awon nako ang
tube basig matanggal.”She also added: “Maka-lingkod na ko usahay sa
akoa. Maka lakaw napud ko sa CR, basta
mag-hawak ko sa akong kauban ug sa
pader para di ko matumba.”
Lastly, the patient’s skin is free of swelling,
redness and pus formation at the
surgical site.
Dependent:
Administer medications prior to
activity as needed. (R) To permit maximal
effort and involvement in activity.
Collaborative:
Consult with physical/ occupational therapist
as indicated. (R) To develop individual exercise/ mobility
program and identify appropriate adjunctive
devices.
PROGNOSIS /DISCHARGE PLAN (M.E.T.H.O.D)Prognosis
GOOD
3
FAIR
2
POOR
1
JUSTIFICATION
Onset of the illness Since the signs and symptoms of illness appeared before
May of 2009, hypertension and asthma could mask lung
adenocarcinoma. The onset of illness may have begun
during her early years, or that her real parents might
have a history of cancer. Nonetheless, the prognosis for
the onset of illness is fair for the patient does not smoke,
the cause of her illness could not be verified, and that the
real onset of illness is unknown.
Duration of illness Her adenocarcinoma has been diagnosed by June 2009.
She has a difficulty of breathing (a symptom of lung
adenocarcinoma) by May 2009. The prognosis for the
duration of illness is fair, not that bad not that good
because as just said, the diagnosed disease of asthma
and hypertension stage II could mask the sign and
symptom of lung cancer. Moreover, she prompted to
seek medical advice a month later to verify the status of
her perceived illness. This later turned out to be more
severe than the previous diagnoses.
Precipitating factors The patient has no diabetes mellitus. She has no history of food and drug allergies or hypersensitivities. Air pollution, environmental and occupational exposure to harmful gases second hand smoking, and dietary factors are absent.Also, consuming alcoholic beverages was something she did not do.
Willingness to take
medications and
treatment
The patient has a positive approach towards her disease.
During the course of the interview by Ms. Dujali, Ms.
Dayanghirang and Ms. Delima, the patient was seen to be
attentive of the doctor’s instructions, and is following
RN’s instructions such as proper ways of breathing
effectively, and ways on how to keep the tube safe. She
also displayed the willingness to undergo series of
diagnostic procedure and another operation which is due
a week after July 2, 2009.
Age The patient’s age is of hindrance to the effectiveness of
the medications given and also she is more exposed to
absorbing harmful radiation resulting to more dangerous
cases such as affecting normal cells instead of cancerous
cells. The principle of pharmacology states that a
geriatric client is more susceptible to drug toxicity as the
renal function of the kidneys decreases with age, thus
the excretion of the “inactive” products in the
medication given could accumulate in the body and thus
the toxicity. Also the patient’s health is declining,
theorists point out that the cardiac capacity decreases, as
well as the integumentary system loses its capacity to
repel any bacterial invasion, and also the neurologic
capacity decreases which might be due to the decreasing
number of neurotransmitters and hormones in the brain/
nervous system. Thus the patient is more likely to be at
risk for fatigue, injury and infection.
Environmental
factors
The client stated that there was no prolonged exposure
to radiation during her lifetime, and that she lives in a
community/subdivision where there is at least a
conducive place for her to get cured and also, her
statement that none of her family members are smoking
indicates that factors that could exacerbate the disease
process are not absent and less likely to cause further
damage.
Family Support Upon interview of the client on July 3, 2009 at around
5pm, her family members were present. According to our
groupmates they were numerous and the room was
flocked with people. This only points out that her family
is supportive of the patient. Her children are in the
hospital throughout their mother’s hospitalization and
are participative and interactive during the course of
treatment and diagnostic procedures done to the
patient.
Total 4 3 2
Computation:
Poor: (2*1)/7 = 2/7= 0.2857
Fair: (3*2)/7 = 6/7= 0.8571
Good: (4*3)/7 = 12/7=1.7143
Total: =20/7 or 2.8571
approximately 3 (fair)
Rationale for Fair Prognosis
The patient has a fair chance of recovering from her disease as evidenced by the result
shown above; though the prognosis is open for debate and discussion. The fact that she has
undergone series of diagnostic tests and one surgical procedure which is chest tube thoracostomy,
the purpose of which is to drain excess pleural fluid in the lungs, to relieve pleural effusion, a
complication of Lung cancer. The CTT insertion relieves massive pleural fluid alone, but do not cure
cancer. However, undergoing surgery or any other surgical procedures or also chemotherapy could
help in prolonging the life of the patient and alleviate the suffering of the patient but does not
qualify to guarantee freedom from cancer.
Lung cancer surprisingly affects women than men. Lung adenocarcinoma is “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.” Thus the effects lung cancer are
irreversible and as of today’s medical approach are still in queue for new innovations for cure and
treatment. Regardless of these things, the patient is positive about her condition. She is also more
than willing to comply with medication regimen as well as tests to treat her condition. In addition,
her family’s support helps her a lot in dealing with the disease and psychological effects of it. Lastly,
faith comes in play with the treatment since the patient seeks God, which could help her cope well,
and which might become a reason for hope.
Discharge Plans or [METHOD]:
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.
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.
RECOMMENDATION
This case study has provided the student nurses of the Ateneo de Davao University with
profound knowledge and understanding about the information gathered about and related to the
patient’s disease: lung cancer. In order to ensure that health and wellness is maintained the group
would like to recommend the following:
To the Patient
That her attitude towards her disease is an avenue for growth and mature approach
towards life. With regard to this, we would like to encourage the patient to continue her approach
towards her disease and moreover, to continue to take her medications and follow the doctor’s
advices whenever applicable. In addition, the patient should verbalize any concern and should talk
about her anxieties openly to her family. Lastly, she should continue to cooperate and actively
participate for the betterment of her own health.
To the patient’s family
The family should guide and help the patient in relieving complications brought about by
the disease. Thus, the family should encourage the patient to take her medications and should there
be an onset of pain/discomfort/any conditions that can be fatal to the patient, must seek medical
advice without the second thought. Next, the family should openly communicate with the patient
and they should let the patient verbalize concerns be it fear, anxiety or need. Lastly, the family
should not fail to comfort the patient and be there for the patient.
To the student nurses
This case study is of great help, for cancer is a disease that is of great threat to the humanity
nowadays. This case study should help us to understand what the disease is about, consequently
applying it to real world practice such that, this case study was formed.
Nurses deal with lives and we dealt with one life through this case study. We recommend
amongst ourselves to use the knowledge and skills learned from this case study to helping future
patients with similar conditions by enabling and fostering the values instilled by the Ateneo de
Davao and the ideals, practices, and theories taught by the College of Nursing.
Next, we should also learn on how to properly prioritize needs by the client. We should also
further promote health by providing more health teachings to our clients, and also by becoming a
role model to them. We should also learn how to give support and guidance to persons whom we
consider as recipients of care.
Death is the greatest anxiety of our patient for our case study. CANCER= DEATH SENTENCE.
So, we student nurses should possess empathy, genuineness and a caring attitude which would
greatly help the patient overcome, or to reduce anxiety of death.
To the Ateneo de Davao University College of Nursing
The mechanism that provides student nurses a stage where in they act as professional
nurses is the AdDU College of Nursing. The faculty and staff are encouraged to giving their students
quality and “excellent” education standards, which would elevate Ateneo as one of the best nursing
school in the Philippines. Also, we should also like to recommend continuing to provide exposures
to the students to provide us a pathway to learn and eventually to success.
To the Professional Medical Arena Worldwide
Cancer is a disease that is often not anticipated by the patient and globally is a pandemic,
affecting thousands of people every year. Doctors, nurses, medical technologists, scientists, and all
the member of the health sciences, must continue to researching cure and treatment for cancer.
That we must continue to update ourselves with new procedures and techniques to help alleviate
the suffering of the persons. Lastly, no barrier, regardless of race, gender, ethnicity and age, should
prevent us from sharing knowledge regarding the cure, transmission, and any other information
about diseases.
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Buchfa, Fries, Nursing Procedures. 4th edition, Lippincot’s Williams and Wilkins. 2000
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