A Case Study

Presented to the Faculty of

The Ateneo de Davao University
College 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. Dayanghirang

Deana Charise Delima
Gil Albert Doromal
Ana Patricia Dujali
Kevin Sam Eliseo
Fiel Ronan Leo Fortez
Katreena Galang
Kiershane Joven
Kristian Jake Lad
Almira Latip

BSN-3F

July 2009
TABLE OF CONTENTS
Table of Contents................................................................................i
Acknowledgement...............................................................................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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ACKNOWLEDGEMENT
The 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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INTRODUCTION
In the year 2000, the Philippines had a total number of 6,395 reported deaths

that was caused by cancer of the lungs, as documented by the DOH (Philippine

Health Statistics 2000, DOH)

Slow-growing lung adenocarcinoma, in actuality, is the most common kind of

lung cancer -both in smokers and non-smokers, and in people under age 45.

Adenocarcinoma makes up for about 30 percent of primary lung tumors in male

smokers and 40 percent in female smokers. For non-smokers, these percentages

approach 60 percent in males and 80 percent in females. This is also more common

in Asian populations. Although smoking frequently causes this type of cancer,

secondary risk factors include age, family history, and exposure to secondhand

smoke, mineral and metal dust, asbestos, or radon. Symptoms develop slowly as

well. They include coughing, shortness of breath, wheezing, chest pain and bloody

sputum. Sometimes, this illness may appear at first to be pneumonia or a collapsed

lung.

Sometimes the spread of this cancer produces large amounts of fluid building

up around the lung. In this case, doctors perform Chest tube thoracostomy. It is

done by placing a hollow plastic tube between the ribs into the chest to drain fluid,

blood, or air from the space around the lungs. Pleural effusion, the term used to call

the excess fluid that had accumulated in the pleural cavity, which is the fluid-filled

space that surrounds the lungs. The excess amount of this fluid affects the lungs by

limiting the expansion of the lungs thus, it impairs breathing.

The group chose 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

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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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OBJECTIVES
General 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;

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• 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;

• 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.

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PATIENT’S DATA

Personal Data:

Patients Name: Beachin’ Barato

Age: 65 years old
Gender: Female
Birth date: December 11, 1942
Address: Davao City
Nationality: Filipino
Religion Christianity [Roman Catholic]
[Domination]:
Civil Status: Married
Educational High School Graduate
Attainment:
Occupation: Retired High School Teacher for 10 years
Weight: 62 kilograms

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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 H244
Numbers]:
Attending Physician: Dr. Allan P. Arreola
Chief complaint: Difficulty breathing
Admitting and Final Left Massive Pleural Effusion secondary to Lung
Diagnosis: CA
Vital signs on
admission: 36ºC Degrees Celsius
87 Beats per Minute
Temperature:
23 Cycles per Minute------------rapid
Pulse Rate:
breathing!!!!!!!!!!
Respiratory Rate:
130/ 90 Millimeters per Mercury
Blood pressure:
Surgical Procedure
Chest Tube Thoracostomy
Done:
*Pre-operation Diagnosis: Massive left pleural effusion
secondary to lung
cancer
*Surgeon: Dr. Lei
*Anesthesiologist: Dr. Barinaga

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Source of Patient; Patient’s daughter-in-law; Husband
information:

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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

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provided her good experience to be a teacher of Religion in Davao City

National High School for 10 years.

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

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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.

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

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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.

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

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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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 GENEALOGY
Legend:
Male
Mikaela
Schrema Lady Female Sam
Banes
Prime Gaga Witwicky
Client

Army Army John Pugad Lasing

Mudflap Pocahontas
Captain Navy Smith Babay Torres

Beachi
Mr.
Mr. Elephant n’ Roberti
Megatron Shaggy Lover
Boombastick astic Barato Jaworski
Lover

*unable to identify status (living or deceased); health history

(diabetic, hypertensive, etc) because client cannot provide
information

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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 - An adult’s identity and ACHIEVED - It can be said that although the patient
differentiati feeling of worth are highly cannot do her routinely activities without
on versus dependent on that persons the partial aid of the nurse and that she
work-role work role. cannot teach anymore, she is well aware of
preoccupati her body capability and accepts the things
on she cannot do. Thus, the patient belongs to
ego differentiation aspect.

ACHIEVED -During the interview, the patient is aware

-Body - This task calls for an of her decreasing muscle strength and that
transcenden individual to adjust to she accepts her deteriorating body
ce versus decreasing physical function. She always manages to adapt
body capacities and at the same with it with the help of her children. Thus,
preoccupati time maintain feelings of body transcendence is prevalent.
on well-being. Preoccupation
with declining body
functions reduces
happiness and satisfaction
with life.
-c
ACHIEVED

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 - Ego transcendence is the
-Ego acceptance without fear of
transcenden one’s death as inevitable.
ce versus This acceptance includes
ego being actively involve in
preoccupati one’s own future beyond
on death. Ego 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 Justification

Integrity vs. This involves reflecting on the ACHIEVED A clear understanding of patient’s life is
Despair past and either piercing together necessary. It can be said that her
a positive review or concluding satisfaction on her life was achieved. She
that ones life has not been well even told us about her past experiences
spent. and the places she had been. She smiles
when she talked about her children and
how successful they were. There is an

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 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.

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 Justification

Later In this stage, once that the later
maturity maturity had been established
stage and reached it is expected that
the person will do the following:
• Adjusting to decreasing ACHIEVED - the patient is completely aware of her
physical strength and weakening body
health

• Adjusting to requirements ACHIEVED -She is not working currently and that her
and reduced incomes children provided her of her basic needs

- Other than her children and

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 grandchildren, she used to be with her
• Establishing an explicit ACHIEVED husband and her friend in their
affiliation with once age neighborhood that has the same age as
groups her.

ACHIEVED -she is staying with her husband. More

• Establishing satisfactory often than not, she visits her children and
physical living grandchildren
arrangements.

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 Justification

Formal In this stage individuals move ACHIEVED One great manifestation of this stage is
Operational beyond concrete experiences and that a person is able to finish school,
Stage: think in abstract and more logical reason-out abstractly and logically, able to
ways. As part of thinking more draw answers from information that is
abstractly, an individual develop available, and able to apply whatever is
images of ideal circumstances. being thought in school. The first one is not
This describes how a person that important at all because in this
thinks systematically and uses country not are able to finish school at the
more logical reasoning. It is also right time. But the other manifestations
characterized thinking according that is correlated to this stage is greatly
to ethics and justice. They can evident to Ms Beachin’ Barato. First, she
also reason about hypothetical was able to apply her learning's in her life
possibilities and deduce new experiences and shared this knowledge

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concepts. 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”

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 The clinical practice of Medical-surgical nursing (1988)
By:Marjorie Beyers, R.N.,M.S.N and Susan Dudas, R.N.,M.S.N

“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

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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.

PHSYICAL ASSESSMENT
Date of Assessment: July 4, 2009

Time of Assessment: 5:25 pm

Location of Assessment: Davao Medical School Foundation Hospital

Vital Signs

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 Temperature : 36 degrees Celsius
Pulse Rate: 87 Beats per Minute
Respiratory 23 Cycles per Minute---

Rate: 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

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 6 th 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.

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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.

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.

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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.

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

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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 nipples. Breast is noted to be saggy in

contour and in shape as a sign of breastfeeding and child birth.

Abdomen

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 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.

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

28 | P a g e
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.

29 | P a g e
ANATOMY AND PHYSIOLOGY
The 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.

Each lung has sections called

lobes. The left lung has two lobes,

while the right lung is slightly larger and

has three lobes. Two tubes called

bronchi, lead from the trachea (windpipe)

to the right and left lungs. These

bronchi are sometimes also

involved in lung cancer disease process.

30 | P a g e
 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

31 | P a g e
subset of adenocarcinoma. It forms near the lungs' air sacs. Recent clinical research

has shown that this type of cancer responds more effectively to the newer targeted

therapies, and 4. Large-cell undifferentiated carcinoma. This cancer forms near the

surface, or outer edges, of the lungs. It can grow rapidly.

The second type of lung cancer is the Small cell Lung Cancer. SCLC accounts for

about 20% of all lung cancers. Although the cells are small, they multiply

quickly and form large tumors that can spread throughout the body. Smoking

is almost always the cause of SCLC.

Adenocarcinoma

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.

32 | P a g e
 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.

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.

33 | P a g e
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:

• Stage IA: The tumor is in the lung only and is 3 centimeters or smaller.

34 | P a g e
• 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).

35 | P a g e
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.

• 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).

36 | P a g e
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:

---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

37 | P a g e
 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 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

38 | P a g e
 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.

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.

39 | P a g e
 • 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 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

40 | P a g e
thickening of visceral or

parietal pleura.

41 | P a g e
ETIOLOGY and SYMPTOMATOLOGY

ETIOLOGY

Predisposing Present/
Rationale Justification
Factors Absent
Genetic Absent The incidence of lung The client does not
predisposition cancer in close relatives report anyone in the
of clients with lung family or kin having a
cancer appears to be lung cancer.
two or three times that
of the general
population regardless of
smoking status.
Smeltzer, Suzanne C.
Textbook of Medical-
Surgical Nursing. 10h
edition
Mutations in both the
p53 gene and the K-ras
oncogene are most
commonly observed in
lung cancer.
Johnson, B.E., Kelly M.J.

42 | P a g e
 Precipitating Present/
Rationale Justification
Factors Absent
• Cigarette or Absent Tobacco use is According to the client,
tobacco responsible for more she never tried smoking
smoking than one of every 6 in her entire life.
deaths from pulmonary
SYMPTOMATOLOGY 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
Second hand Absent Passive smoking is The client stated that
smoking blamed to be the second there was no prolonged
cause of lung cancer. In exposure to cigarette or
other words, people who tobacco smoke during
involuntarily inhale her lifetime.
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
43 | P a g e
exposed.
Smeltzer, Suzanne C.
Textbook of Medical-
PATHOPHYSIOLOGY

Damage in DNA

Activation Repair

Failure of DNA repair

Genetic mutation occurs

Type II Type III

Type I Occurs when one Occurs when an additional
Occurs when one gene amino acid is omitted, codon is added to the
is omitted completely making a false DNA protein

Modified proto- Deactivation of tumor Activation of

oncogene function suppressor genes apoptosis

44 | P a g e
 Transformation of
proto-oncogenes to
oncogenes

Unregulated cell growth

and differentiation

Transformation of
epithelial cell in the
tracheobroncho airways

Carcinogens= air pollutants

Malignant cell

Transfer of wrong DNA

to daughter cell

Accumulation of malignant cell =

pulmonary epithelium transformed
to adenocarcinoma

45 | P a g e
 The adenocarcinoma is presented more
peripherally as peripheral mass and nodules
often metastasize.

Sign and symptom: Lung adenocarcinoma

Dyspnea

If Treated: If Untreated:
 Radiation Therapy
 Chemotherapy

Metastasis occurs
Good Prognosis

Cancer cells spread to

nearby lymph nodes
and organs

Alteration in organ
function

Multiple organ failure

Death

46 | P a g e
DOCTOR’S ORDER
Date ordered Order Rationale Remarks
July 2, 2009 Low salt, low fat Low fat low salt Done
diet. diet prevents
increase in blood
volume thus
decreasing the
possibility of fluid
in the lungs.
VS monitoring To monitor vital Done
q4h signs so that any
discrepancies will
be referred as
follows.
Complete Blood It used to Done
Count 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.
Platelet Platelets are disk- Done
Aggregation Test 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

47 | P a g e
 measure the
cloudiness
(turbidity) of
blood plasma.

Blood Test An analysis of a Done

sample of blood,
especially for
diagnostic or
therapeutic
purposes.
Prothrombin time The prothrombin Done
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

48 | P a g e
 37°C for one to
two minutes. The
test is timed from
the addition of
the calcium
chloride until the
plasma clots.
Chest X- ray for A chest x ray is a Done
Physical procedure used
Assessment to evaluate
organs and
structures within
the 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.
Electrocardiogra The Done
m electrocardiogra
m (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

49 | P a g e
 electrodes placed
at certain points
on the skin.
O2 Saturation at This will Done
ER to record 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.
Theopylline These Done
(Nuelin) medications help
alleviate patient’s
Norvasc pain, prevent
complications
Vitamins + and help in the
Minerals curative/palliative
(Centrum) process.

NPO status Ensuring NPO Done

status will
prevent
aspiration of
fluids during
surgical
procedures.
For stat CTT A chest tube Done
insertion at 10pm insertion is a
under sedation 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

50 | P a g e
 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.

51 | P a g e
DIAGNOSTIC EXAM
COMPLETE BLOOD COUNT WITH PLATELET COUNT
Result
Normal Clinical
Date Exam Rationale of Nursing Responsibilities
Value Significance
Patient
Hemoglobin 120– 160 The test that 122 Normal 1. Discuss and explain the procedure
and purpose of the test.
g/dL measures the g/dL
amount of 2. Inform the patient that no fasting is

hemoglobin needed.

per liter of
3. Assess the patient for any factor that
blood

52 | P a g e
 Result
Normal Clinical
Date Exam Rationale of Nursing Responsibilities
Value Significance
Patient
July 2, Hematocrit M: 42- The test 35% Normal will probably affect the results of the
test.
2009 52% measures the
F: 37- percentage of
47% RBC in the
total blood
volume

53 | P a g e
 Result
Normal Clinical
Date Exam Rationale of Nursing Responsibilities
Value Significance
Patient
WBC count 0.5-10 The test 13.6 X HIGH:
4. Make sure patient is well hydrated.
X10^9/L measures all 10^9/L Conditions that
Dehydration elevates the test results.
cause high WBC
leukocytes
values include
present in 1 infection, 5. If patient is connected to IVF, make
inflammation, sure that the blood is not taken from
cubic
damage to body the arm connected to the IVF.
millimeter of tissues, severe Hemodilution causes false decrease of
physical or the test results.
blood.
emotional stress
(such as a fever,
6. After the puncture, assess the site
injury, or
for bleeding or bruising.
surgery), burns,
kidney failure, 7. If patient is under treatment from an
lupus, infection, inform the patient that the
tuberculosis, test will be repeated to monitor
rheumaoid progress.
arthritis, 8. Any abnormality noted will be
malnutrition, reported to the physician.
leulemia, and
diseases such as
cancer.

54 | P a g e
 Result
Normal Clinical
Date Exam Rationale of Nursing Responsibilities
Value Significance
Patient
Monocyte 2 – 10% Monocytes 2% Normal
have
phagocytic
action. It
removes dead
or injured
cells, cell
fragments,
and
microorganis
m. This test is
done to
diagnose an
illness such as
inflammatory
diseases.

55 | P a g e
 Result
Normal Clinical
Date Exam Rationale of Nursing Responsibilities
Value Significance
Patient
Eosinophils
initiate
allergic
responses and
act against
Eosinophils 1 – 8% parasitic 2% Normal
infestation.
The test is use
to diagnose
worm
infestation.
RBC count 4.0-5.0X The test 4.73X Normal
10^12/L measures the 10^12/
circulating L
RBCs in 1
cubic
millimeter of
blood.

56 | P a g e
 Result
Normal Clinical
Date Exam Rationale of Nursing Responsibilities
Value Significance
Patient
The test
measures the
150- amount of 290
Thrombocyt
300X platelets that X10^9/ Normal
es
10^9/L are important L
for blood
clotting.
The test
meaures the
percentage of
Lymphocyte the principal
20-40% 20% Normal
s component of
the body’s
immune
system.

57 | P a g e
PROTHROMBIN TME
Result Clinical
Normal
Date Exam Rationale of Significanc Nursing Responsibilities
Value
Patient e
Prothrombi 12-15 The 12.4 Normal 1. Discuss and explain the
procedure and purpose of the
n time seconds prothrombin second
test.
time is the s
2. Assess the patient for any
time it takes
factor that will probably affect
plasma to clot the results of the test.
after addition
3. Check to see if the patient is
of tissue taking any medications that may
affect test results. This
July 2, factor. This
precaution is particularly
2009 measures the important if the patient is taking
warfarin, because there are a
quality of the
number of medications that can
extrinsic interact with warfarin to increase
or decrease the PT time.
pathway (as
well as the 4. After the procedure,there must
be routine care of the area
common
around the puncture mark. Apply
pathway) of moist warm compresses on the
area around the puncture mark.
coagulation.

58 | P a g e
 Result Clinical
Normal
Date Exam Rationale of Significanc Nursing Responsibilities
Value
Patient e

The test is to
5.Apply pressure for a few
know if there seconds and the cover the wound
Internation with a bandage.
is a high
al
0.8–1.2
Normalized chance of 0.07 Normal 6. Inform the patient that there
Ratio might be mild dizziness and the
bleeding or
possibility of a bruise or swelling
high chance in the area where the blood was
drawn.
of blood clot.

59 | P a g e
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  Oral theophylline for acute bronchospasm in patients not currently receiving
Dosage 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

60 | P a g e
 dosage is 3 mg/kg q 6 hours.
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.

61 | P a g e
Mode of Action Inhibits Phosphodiesterase, the enzyme that degrades cAMP, resulting in relaxation of
smooth muscle of the bronchial airways and pulmonary blood vessels.

Contraindicati Contraindicated in patients hypersensitive to xanthine compounds (caffeine, theobromine)

on and in those with active peptic ulcer or poorly controlled seizure disorders.

Drug Drug-drug. Adenosine: may decrease antiarrhythmic effect. Higher doses of adenosine may
Interactions 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.

62 | P a g e
 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.
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 CNS: restlessness, dizziness, insomnia, seizures, headache, irritability, muscle twitching.
Effects CV: palpitations, sinus tachycardia, arrhythmias, extrasystoles, flushing, marked hypotension.
GI: nausea, vomiting, diarrhea, epigastric pain.
Metabolic: urinary catecholamines
Respiratory: respiratory arrest, tachypnea

Nursing • Dosage may need to be increased in cigarette smokers and in habitual marijuana
Responsibilitie smokers because smoking causes drug to be metabolized faster.

63 | P a g e
s • Give the drug around the clock, using extended-release product at bedtime.
• Monitor vital signs; measure and record fluid intake and output. Expect improved
quality of pulse and respirations.
• Patients metabolize xanthenes at different rates; dosage is determined by monitoring
response, tolerance, pulmonary function, and drug level. Drug levels range from 10 to
20 mcg/ml; toxicity may occur at levels above 20 mcg/ml.
• ALERT: evidence of toxicity includes tachycardia, anorexia, nausea, 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

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 result.

Generic Name amlodipine besylate 5 mg , 1 tab OD ac

Brand Name Norvasc
Classification calcium channel blocker; Pregnancy risk category C
Indication and  Chronic stable angina, vasospastic angina
Dosage (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.

Contraindicati Contraindicated in patients hypersensitive to drug.

on
Drug None reported.

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Interactions
Side/ Adverse CNS: headache, somnolence, fatigue, dizziness, light-headedness, paresthesia.
Effects CV: edema, flushing, palpitations.
GI: nausea, abdominal pain.
GU: sexual difficulties.
Musculoskeletal: muscle pain.
Respiratory: dyspnea.
Skin: rash, pruritus.

Nursing • ALERT: Monitor patient carefully. Some patients, especially those with severe obstructive
Responsibilitie coronary artery disease, have developed increased frequency, duration, or severity of angina
s 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.

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67 | P a g e
Generic Name Multivitamins + minerals 1 tab OD ac
Brand Name Centrum®
Classification Vitamins &/or Minerals
Indication and Complete multivitamin & mineral formula.
Dosage 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

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 • 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

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 • 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
• 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

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 • Necessary for red blood cell formation
12) Biotin
• 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

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 • Involved in synthesis of protein and cholesterol and in the absorption of carbohydrates
16) Iron
• Essential part of hemoglobin

• 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

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 • Important for night vision
20) Calcium
• Helps build and maintain strong teeth and bones
• Helps to reduce risk of osteoporosis
• 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

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 • 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
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
Contraindicati 1. If the multivitamin supplement contains fluoride, check with doctor. Patients should not use it

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on 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-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 • calcium increases toxicity of beta-methyldigoxin

Interactions • 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

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 • 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
• 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 • vit A

Effects 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 B1
No reported adverse effects at doses studied up to approximately 50 mg / day

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• vit B2
No reported adverse effects in studies with doses up to 200 mg/day
• vit B6
none reported
• vit B12
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.
• 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

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 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
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

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 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
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 1. Do not use supplements as a replacement for a diet rich in essential vitamins and minerals.
Responsibilitie Encourage the patient to eat the right kind of food for it contains many important ingredients
s 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

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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 Chest Tube Thoracostomy
Performed:
Type of Anesthesia: General
Complete Name of Dr. Geoffrey Lei
Surgeon:
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 report
o What to bring such as insurance card, list of
medications and allergies
o What to leave at home such as jewelry,
watch, medications and contact lenses
o What to wear which is loose-fitting,
comfortable clothes and flat shoes

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 o To take nothing by mouth for six to 12 hours
before the surgery.
• Request pain medications as needed to relief the
patient from pain
• 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 in
o OR services form accomplished
o Patient is scheduled in OR
o Anesthesiologist informed
o Medicines in
o Blood Typed and Matched
o Field of Operation prepared
o Sponged or bathed
o Diet instruction given
o Enema given
o Make-up and nail polish removed
o Jewelry and denture removed
o Oral hygiene given
o Patient changed into patient’s gown
o Indwelling catheter inserted
o 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

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 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.

• 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 room
o Protects patient’s safety and health by
monitoring the activities of the surgical team
o Checks and verifies the consent form
o Ensures fire safety precautions, cleanliness,
proper temperature, humidity and lighting of the
operating room
o Monitors safe functioning of the equipments
o Coordinates with the surgical/perioperative
team and monitors aseptic practices
o Documents operating room surgical activities
o Count all needles, sponges and instruments
together with the scrub nurse

• For registered nurse first assist:

o Suturing and handling of tissues
o Providing exposure at the operative field

• For the scrub nurse:

o Setting up sterile tables
o Assisting the surgeon and assistant surgeon,
taking care of tissue specimens

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 o Count all needles, sponges and instruments
together with the circulating nurse
o 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, 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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86 | P a g e
87 | P a g e
 • 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.

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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 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

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 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.

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

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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 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

93 | P a g e
environment where privacy is considered for the preservation of the
client’s integrity.

94 | P a g e
NURSING CARE PLAN
Patient’s Name: Beachin’ Barato Age: 65 years old
Chief Complaint: Difficulty of Breathing Attending Physician: Dr. Allan P.
Arreola
Gender: Female Shift: 3-11
Diagnosis: Massive pleural effusion secondary to lung cancer. Date: July 2, 2009
Room No.: 4C 444 to 244

Date Cues Nursing Diagnosis Need(s Objective(s) of Interventions Evaluation

and ) care
Time
July Subjective Impaired gas A Within 3 hours Independent: July 3, 2009 at
3, cues: exchange related to C of nursing care, 7:30pm
200 Verbalized disease process as T the patient will Monitor vital signs.
9 difficulty in evidenced by I experience (R)To evaluate GOAL PARTIALLY
at breathing. dyspnea. V improved gas degree of MET.
5:00 I exchanged as compromise.
pm Objective (R) The presence of T evidenced by: Within three hours
cues: pleural fluid (a Y Assess lung of nursing care, the
-Rapid complication of lung a. Improved sounds, respiratory patient stated
breathing cancer wherein E oxygenati rate and effort and acceptable
pleural fluid collects X on (within use of accessory dyspnea.
- in the pleural space E 88%- muscles. (R) “Nakakahinga na
Respiratory as a result of irritation R 100% O2 Respiratory rate ako ng mas maayos
rate: 23 or obstruction of the C saturation less than 12 or kaysa kanina.” In
cycles per venous drainage by I ) and more than 24 or addition, the
minute the tumor), may S absence use of accessory patient participated
- O2 hinder adequate lung E of muscles indicate in treatment
saturation expansion, and it respirator distress. regimen, such as
of 65% causes the pleural y distress. Diminished lung breathing exercises.
membranes (essential b. Statemen sounds indicate
for diffusion of gases) t of possible poor air However, the
to compress thus acceptabl movement and patient still has
 affecting gas e impaired gas respiratory distress
exchange. dyspnea. exchange. and has 02
c. Participati saturation by
on in Observe skin and 7:30pm of only
treatment mucous 73%.
regimen membranes for
(breathin cyanosis. (R)
Source: g Cyanosis indicates
William, L. Hopper, P. exercises) poor oxygenation.
(2007) Understanding within the Oral mucous
Medical Surgical level of membrane
Nursing: Third Edition. ability. cyanosis indicates
Philadelphia: F. A serious hypoxia.
Davis.
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 Subjective: Acute pain related to C Within 8 hours Independent: July 3, 2009 at
3, “Ayaw i- chest tube O of nursing care, 7:30pm
200 taas ang thoracostomy G the patient will: Assess pain level
9 at ulohan procedure as N q4h and prn. (R) GOAL MET.
5pm nako, kay evidenced by guarded I a. State that Good assessment
naga-sakit and expressive T her pain must guide The patient’s pain
ang behaviour. I is treatment. was relieved as
akoang V relieved evidenced by pain
dughan.” (R) The effect of E (rating of Assess sedation scale of 4 out of 10.
anaesthesia can be 3-5 out of and respiratory And the patient
Objective: diminished after the P 10 in pain status frequently. verbalized methods
patient has been fully E scale). (R) Opioids are that provided relief
-Covers awaked and R b. Verbalize given carefully such as the pain
/Protects conscious. The hole C methods because they may medications given,
the painful made by the incision E that reduce respiratory distraction
area and insertion of chest P provided rate and cough techniques by
 tube can be painful, T relief. reflex, which is constantly talking
-Resistance as movements often U vital to achieve to significant
when it cause tension and A normal breathing others.
comes to “pull” to the tube, L pattern and
lifting the thus the perceived clearing the airway.
head part. pain.
Include
-Restricted Source: nonpharmacologica
movements William, L. Hopper, P. l pain interventions
. (2007) Understanding (such as distraction
Medical Surgical and relaxation). (R)
-Pain scale Nursing: Third Edition. It will help pain
of 6 out of Philadelphia: F. A control and reduce
10. Davis. 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 who is
pain free will be
better able to
participate in care
and take measures
to prevent
complications such
as coughing and
ambulating.
July Objective: Risk for infection H After 5 hours of Independent: July 3, 2009 at
3, related to bypass of E nursing care, 10pm.
200 Post-op normal respiratory A the patient will: Use good-
9 status: defense mechanism. L handwashing GOAL MET.
at Chest tube T a. Be free of technique. (R)
5pm attached to (R) Patients H infection Handwashing is After rendering 5
patient. diagnosed with as important in hours of nursing
cancer are often P evidence preventing care the patient
immunocompromised E d by infections. has a temperature
 which might be due R Temperat of 36.5 degrees
to the C ure, Blood Monitor and report Celsius and a BP
diagnostic/palliative/c E Pressure signs and of 120/70. The
urative procedures P within symptoms of patient’s incision
they have undergone. T normal infection: fever, site is also free of
Such patients are at I limits and increased redness and
risk for infection, O absence respiratory rate. (R) swelling.
which might be N of Early recognition
systemic, and most complicat and treatment of
especially to patients H ions (such infection enhances
who have a portal of E as outcomes.
entry (for this A redness
instance the tubing) L and Palpate around the
which might be an T swelling insertion sites for
pathway for H at the crepitus. (R)
microorganisms to incision Crepitus is
bypass normal M site). associated with gas
defense mechanism A gangrene, rubbing
by the body, and N of bone fragments,
directly enter the A or crackles of a
body. G consolidated area
E of the lung.
M
Source: E Check all tubing for
William, L. Hopper, P. N kinds, breaks, or
(2007) Understanding T broken
Medical Surgical connections. Verify
Nursing: Third Edition. that all connections
Philadelphia: F. A are securely taped.
Davis. (R) Microorganisms
may infiltrate if
there 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 Subjective: Readiness for C After 2 days of Independent: July 4, 2009 at
3, “Although enhanced family O nursing care ( at 6:30pm.
200 ganoon na coping related to P July 4, 2009) the Observe
9 at nga ang needs(physical/ I patient will: communication GOAL PARTIALLY
5:30 sitwasyon, psychological) of the N patterns of family. MET.
pm sana lang patient met as G a. Express Listen to family’s
nga evidenced by patient S willingnes expression of hope, After 2 days of
gumaling having a positive T s to look planning, and effect nursing care the
ako. Yan approach towards R at own of disease on patient expressed
ang disease, and family E role in the relationship/s or willingness to look
ipinagdaras members open to S family’s life. at own role in the
al ko every treatment programs S growth. (R) To assess family’s growth. For
day.” and support groups. b. Verbalize situation and to this case, the
T tasks observe family’s disease. She said
Objective: (R) The fact that O leading to behaviour and that as much as
individual needs are L change. attitude towards an possible, her
-Patient being sufficiently E c. Report illness. potential as human
attentive to gratified and adaptive R feelings being will not be
instructions tasks are effectively A of self- Note client’s hampered by the
given by addressed and the N confidenc expressions. disease and her
the doctor. surfacing of enabling C e and E.g Life has more family will go on
self- actualizations E satisfactio meaning to me with their lives as
-Family are met. n with since this has usual. She also
members P progress occurred). verbalized: “Okay
are faithful A being (R) To identify naman ang mga
to T made. changes in values. tambal na
medication Source: Doenges, M. T ginahatag sa akoa.
regimen Moorhouse M. F. E Provide time to talk Nafeel pud nako na
and Geissler- Murr, A. R with family.(R) To murag
constantly (2004). Nurse’s N discuss their view makaginhawa na ko
attending Pocket Guide: Ninth of the situation. ug tarong
 to client’s Edition. Philadelhia: F. pagkatapos sa
needs such A Davis. Discuss importance operasyon.”
as of open However, the
ambulating communication. (R) patient did not
, feeding To assist family to recognize any tasks
the patient, strengthen leading to change
and also potential for in attitude or
providing growth. behaviour.
comfort.
Assist family
members to
support the client
in 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 Subjective: Impaired physical A Within the 2-day Independent: July 4, 2009 at
3, mobility related to C duty the patient 6:30pm.
200 “Dili ko discomfort at surgical T will: Determine degree
9 kalihok ug site and disease I of immobility. (R) to GOAL MET.
at mayo. process. V a. Verbalize assess functional
5:30 Nahadlok I understan ability. Within the 2- day
pm man gud ko T ding of duty the patient
basig (R) Cancer is a Y situation Observe movement verbalized
matanggal. disease that often or risk when client is understanding of
” affects person’s E factors unaware of the situation and
mobility due to X and observation. (R) To risk factors and also
Objective: fatigue and E individual note any individual
imbalance in R treatment incongruencies with treatment. “Pwede
- Inabi nutritional intake C regimen reports of abilities. man ko mulihok,
lity to (which might be due I and pero dapat tan-
turn/ to medications or S safety Support affected awon nako ang
move chemotherapy). The E measures body part. (R) To tube basig
to incision site after . maintain position matanggal.”
lateral chest tube insertion is b. Demonstr of function. She also added:
position not closed, for the ate “Maka-lingkod na
when tube to be detached. technique Perform range of ko usahay sa akoa.
lying in This might cause s that motion exercises, Maka lakaw napud
 bed. friction between the enable passively at first, ko sa CR, basta
- Need surface of the skin resumptio then actively when mag-hawak ko sa
s and the tube which n of the patient is able. akong kauban ug sa
assista might cause activities. (R) This helps pader para di ko
nce discomfort and c. Maintain prevent matumba.”
when restrict movement. skin contracture of the Lastly, the patient’s
sitting integrity arm and shoulder skin is free of
down. as on the affected swelling, redness
Sources: evidence site. and pus formation
Berman. Snyder. d by at the surgical site.
Kozier. Erb. (2007). absence Assist patient to
Fundamentals of of ambulate as
Nursing: eighth swelling, tolerated on first
edition. Pearson redness, day prn.
Prentice hall. and pus (R) Ambulation
William, L. Hopper, P. formation helps maintain
(2007) Understanding at the mobility and
Medical Surgical surgical prevents
Nursing: Third Edition. site. postoperative
Philadelphia: F. A complications.
Davis.
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
GOO FAI POO JUSTIFICATION
D R R
3 2 1
Onset of the Since the signs and symptoms of illness
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 Her adenocarcinoma has been diagnosed by

illness 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 The patient has no diabetes mellitus. She has
no history of food and drug allergies or
factors
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 The patient has a positive approach towards

take her disease. During the course of the
medications interview by Ms. Dujali, Ms. Dayanghirang and
and treatment 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 The client stated that there was no prolonged
factors 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 Upon interview of the client on July 3, 2009 at

Support 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.
Computation:
 Poor: (2*1)/7 = 2/7= 0.2857

 Fair: (3*2)/7 = 6/7= 0.8571

Total 4 3 2
 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.

REFERENCES
BOOKS:
• Broyles, Bonita,. Pharmacological Aspects of Nursing Care, 7th edition

Thompson Learning, 2007,

• Beyer, Dudas,. The clinical practice of Medical-Surgical nursing,Lippincot’s

Williams and Wilkins, 1998

• Bare,Smeltzer, Medical-Surgical Nursing.vol., Mc-Graw Hill. 2000

• Collier, Lewis, Medical- Surgical nursing: Assessment and management of

clinical problems, 2nd edition, Thompson Learning. 1999

• Buchfa, Fries, Nursing Procedures. 4th edition, Lippincot’s Williams and

Wilkins. 2000

• Nettina, S., The Lippincot Manual Of Nursing Practice. Lippincot-Raven

Publishers. 2001,

• Santrock R., Lifespan Development, Mc-Graw Hill 2006

• Stowark, J.,Diseases:Nurse’s Reference Library. Springhouse Corporation

Book Division,1985 Burkhalter, P.K., Donley, D. L., Dynamics of Oncology

Nursing. United States of America: Mc-Graw Hill Inc. 1978

• Smeltzer, S. C., Bare, B. G., Hinkle, J. L., & Cheever, K. H. Brunner &

Suddarth’s Textbook of Medical-Surgical Nursing, 10th Edition Vol. 2.

Philadelphia, PA: Lippincott Williams & Wilkins 2004

• Williams, L. S., Hopper, P. D.Understanding Medical Surgical Nursing, 3rd

Edition. Philadelphia, PA. 2007

• Dooenges, Moorehouse and Murr, Nurses Pocket guide, 9th edition

 • Kozier and Erbs. Fundamentals of Nursing. 8th edition. Vol. 1

• Kozier and Erbs. Fundamentals of Nursing. 8th edition. Vol. 2

• Smeltzer, S. C., Bare, B. G., Hinkle, J. L., & Cheever, K. H. (2008). Brunner &

Suddarth’s Textbook of Medical-Surgical Nursing, 11th Edition Vol. 2.

Philadelphia, PA: Lippincott Williams & Wilkins

• Williams, L., Hopper, P. Understanding Medical Surgical Nursing, 3rd edition,

International Edition, E.A Davis Company, Philadelphia, 2003

• WORLD WIDE WEB

• http://search.yahoo.com/search?p=chest+tube+thoracostomy&vc=&fr=yfp-
t-501&toggle=1&cop=mss&ei=UTF-8&fp_ip=PH

• http://www.nlm.nih.gov/medlineplus/ency/article/002947.htm

• http://www.uptodate.com/patients/content/topic.do?
topicKey=~OozG5MIXyI4uZb

• http://www.thoracic.org/sections/clinical-information/critical-care/patient-
information/icu-devices-and-procedures/chest-tube-thoracostomy.html

• http://www.umm.edu/ency/article/002947.htm

• http://www.surgicalcriticalcare.net/Guidelines/chest%20tube.pdf

• http://www.hcmc.org/manualHCMC/thoracostomy_tube.htm
• http://lungcancer.boomja.com/Lung-Cancer-Symptoms-15.html
• http://www.nlm.nih.gov/medlineplus/ency/article/003035.htm-

• http://www.aafp.org/afp/20050401/1327.html
• http://www.medicinenet.com/joint_pain/symptoms.htm
• http://www.mayoclinic.com/health/difficultyswallowing/DS00523/DSECTION=sym
ptoms

• http://en.wikipedia.org/wiki/Cough
• http://currentnursing.com/nursing_theory/Henderson.htm
• http://www4.desales.edu/~sey0/orem.html

• http://wps.prenhall.com/chet_george_nurstheory_5/1/345/88528.cw/index.ht
ml