Case Analysis on Lung CA

8/2/2019 Case Analysis on Lung CA

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Saint Louis University

School of Nursing

Graduate School Program

CASE ANALYSIS

In partial fulfillmentOf the requirements

In Oncology Nursing

Submitted to:

Ms. Florence Pulido, RMT,RN,MN

Professor

Submitted by:

BANIQUED, Charmaine Acosta

Submitted on:

March 15, 2012


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CASE ANALYSIS

BANIQUED, Charmaine AcostaPage | 2

A. Identify all the Nursing Diagnoses for M.C.1. Chemotherapy- Related Nursing Diagnoses

a. Anxiety related to prescribed chemotherapy, insufficient knowledge ofchemotherapy, and self-care measures

b. Knowledge deficitc. Altered comfort related to gastrointestinal cell damage, stimulation of vomiting

center, fear, and anxiety

d. Altered nutrition: less than body requirements related to anorexia, taste changes,persistent nausea/vomiting, and increased intestinal mobility

e. Altered oral mucous membrane related to dryness and epithelial cell damagesecondary to chemotherapy

f. Fatigue related to effects of anemia, malnutrition, persistent vomiting, and sleeppattern disturbanceg. Activity intolerance related to imbalance between oxygen supply and demand

h. High risk for colonic constipation related to autonomic nerve dysfunctionsecondary to Vinca alkaloid administration and inactivity

i. Fluid volume deficient related to intestinal cell damage, inflammation, andincreased intestinal mobility secondary to diarrhea

j. High risk for impaired skin integrity related to persistent diarrhea, malnutrition,prolonged sedation, and fatigue

k. Self-concept disturbance related to change in lifestyle, role, alopecia, and weightloss

l. Grieving related to changes in life style, role, finances, functional capacity, bodyimage, and health losses

2. Radiation Therapy- Related Nursing Diagnosesa. Anxiety related to prescribed radiation therapy and insufficient knowledge of

treatments and self-care measures

b. Knowledge deficitc. High risk of altered oral mucous membrane related to dry mouth or inadequate

oral hygiene

d. Impaired skin integrity related to effects of radiation on epithelial and basal cellsand effects of diarrhea on perineal area

e. altered comfort related to stimulation of the vomiting center and damage to thegastrointestinal mucosa cells secondary to radiation

f. Fatigue related to systemic effects of radiation therapyg. Activity intolerance related to imbalance between oxygen supply and demandh. Altered comfort related to damage to sebaceous and sweat glands secondary to

radiation

i.

Self-concept disturbance related to alopecia, skin changes, weight loss, andchanges in role relationships and life styles

j. Grieving related to changes in life style, role, finances, functional capacity, bodyimage, and health losses

k. Altered family processes related to imposed changes in family roles, relationships,and responsibilities


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CASE ANALYSIS


3. Surgery- Related Nursing DiagnosesPREOPERATIVE PERIOD

a. Anxiety/fear related to surgical experience, loss of control, unpredictable outcome, andinsufficient knowledge of preoperative exercises and activities, and postoperative

changes and sensations,

b. Anxiety related to impending surgery and insufficient knowledge of preoperativeroutines, intra-operative activities, and postoperative self-care activities

c. Knowledge deficitPOSTOPERATIVE PERIOD

a. Disturbed body image related to surgeryb. Risk for altered respiratory function related to immobility secondary to post-anesthesia

state and pain

c. Impaired skin integrity related to mechanical trauma secondary to surgeryd. Tissue trauma related to surgical incisione. Risk for infection related to increased susceptibility to bacteria secondary to woundf. Pain related to surgical interruption of body structure, flatus, and immobilityg. Risk for altered nutrition: less than body requirements related to increased protein and

vitamin requirements for wound healing and decreased intake secondary to pin, nausea,

vomiting, and diet restrictions

h.

Risk for colonic constipation related to decreased peristalsis secondary to immobility andeffects of anesthesia and narcotics

i. Activity intolerance related to pain and weakness secondary to anesthesia, tissue hypoxia,and insufficient fluid and nutrient intake

j. Risk for ineffective management of therapeutic regimen related to insufficient knowledgeof care of operative site, restrictions (diet, activity), medications, signs an symptoms of

complications, and follow-up care


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CASE ANALYSIS


B. Nursing Care Plan1. After initial discussion with the physician

Nursing DiagnosisSubjective and Objective

DataGoals- Objectives Nursing intervention Expected outcome

Fear/Anxiety related to

Situational crisis (cancer)

S> Express concerns regarding

changes in life events, feelings

of helplessness, hopelessness,

inadequacy

O>Increase tension, shakiness,

apprehension, restlessness,

insomnia

>Sympathetic stimulation

(increase in vital signs),

somatic complaints (voice

quivering, shakiness)

>Note mild to moderate

anxiety (irritability, impaired

attention)

GOALS: Demonstrate

problem-solving skills

LTO:

>Use resources/support

systems properly.

>Demonstrate use of effective

coping mechanisms and active

participation all throughout the

treatment regimen.

STO:

>Display appropriate range of

feelings and lessened fear.

>Appear relaxed and

report anxiety is reduced to a

manageable level.

Dx> Determine what the

doctor has told patient and

what conclusion patient has

reached.

>Identify stage/degree of grief

patient and SO are currently

experiencing.

>Note ineffective coping, e.g.,

poor social interactions,

helplessness, giving up

everyday functions and usual

sources of gratification.

>Be alert to signs of

denial/depression, e.g.,

withdrawal, anger,

inappropriate remarks.

>Determine presence of

suicidal ideation and assess

potential on a scale of 110.

Tx>Provide open environment

in which patient feels safe to

discuss feelings or to refrain

from talking.

>Fully met if patient:

Demonstrates problem-solving

skills Displays appropriate

range of feelings and lessened

fear.

Appears relaxed and

report anxiety is reduced to a

manageable level.

Demonstrates use of effective

coping mechanisms and active

participation in treatment

regimen.

Uses resources/support

systems properly.

>Partially met if patient:

Has marked difficulty

imploring problem solving

skills because of theoverwhelming feeling of

anxiety

>Unmet if patient:
http://nurseslabs.com/mastectomy-nursing-care-plans/http://nurseslabs.com/mastectomy-nursing-care-plans/


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CASE ANALYSIS


>Maintain frequent contact

with patient. Talk with and

touch patient as appropriate.

>Be aware of effects of

isolation on patient when

required by

immunosuppression.

>Provide accurate, consistent

information regarding

diagnosis and prognosis.

>Permit expressions of anger,

fear, despair without

confrontation.

>Give information that

feelings are normal and are to

be appropriately expressed.

>Stay with patient during

anxiety-producing procedures

and consultations.

>Promote calm, quiet

environment.

Edx>Encourage patient to

share thoughts and feelings.

>Educate patient/SO inrecognizing and clarifying

fears to begin developing

coping strategies for dealing

with these fears.

Does not demonstrate

problem-solving skills and

does not able to cope with the

situational crisis.


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CASE ANALYSIS


>Explain the recommended

treatment, its purpose, and

potential side effects. Help

patient prepare for treatments.

>Explain procedures,

providing opportunity for

questions and honest answers.

>Advise SO to provide

primary and consistent

caregivers

whenever possible.

>Encourage and foster patient

interaction with

support systems

>Advocates in provision of

reliable and consistent

information and support for

SO.

>Include SO as

indicated/patient desires when

major decisions are to be

made.

Ref: Doenges, Marilyn, Nursing Care Plans Guidelines for Individualizing Client Care Across t he Life Span, 7th

ed.

Doenges, Marilyn, Nurses Pocket Guide Diagnoses, Prioritized Interventions, and Rationales, 11 th ed.

Videbeck, Sheila, Psychiatric Mental Health Nursing, 3rd ed.


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CASE ANALYSIS


2. On the admission to hospital at the start of therapy


DataGoals- Objectives Nursing Interventions Expected Outcome

Anxiety related to prescribed

chemotherapy, insufficient

knowledge of the therapy, and

self-care measures

S> Verbalization of the feeling

of anxiety and the problem

>Asks for information

regarding the related factors

stated

>Statements reflecting

misconceptions

O>Note mild to moderate

anxiety

>Inaccurate follow-through of

instructions and procedures to

be done

GOAL: Exhibit increased

interest/ assume responsibility

for own learning by beginning

to look for information and ask

questions.

OBJECTIVES:

>Participate in learning

process

>Identify interferences to

learning and specific action/s

to deal with them

>Verbalize understanding of

condition/ disease process and

treatment

>Identify relationship of

signs/symptoms to the disease

process and correlate

symptoms with causative

factors

>Perform necessaryprocedures correctly and

explain reasons for the actions

>Initiate necessary lifestyle

changes and participate in

Dx>Determine clients extent

of understanding of thetherapy

>Review disease process withand future expectations from

the patient.

Tx>Premedications given asprescribed

>Implement dietary regimen,as individually appropriate

>Active-listen concerns abouttherapeutic regimen/lifestyle

changes.

Edx>Stress importance of

increased fluid intake.>Inform patient to notice dry

mouth, N/V, diarrhea, feelingof tiredness during the therapy,

possible alopecia as thetherapy progresses, and loss of

appetite. Radiation therapyentails markings on the area to

be exposed and need not to beerased afterwards.

>Teach care of the radiationsite (no lotions, mild soap is

Fully met if patient:

>: Exhibited increased interest/

assume responsibility for own

learning by beginning to look

for information and ask

questions.

>Verbalized understanding of

disease process and potentialcomplications.

>Able to correlate symptoms

with causative factors.

>Verbalized understanding oftherapeutic needs.

>Initiated necessary lifestyle

changes and participate intreatment regimen.

Partially met if:

Patient is not able to attain the

goal but can be seen initiating

necessary lifestyle changes


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CASE ANALYSIS


treatment regimen. advised)>Discuss medication regimen;

neutropenic diet.>Identify signs/symptoms

requiring further medicalconcerns.

and participate in treatment

regimen.

Unmet if:

Patient not able to reached the

goal and no objectives wasmet

Ref: books.google.com.ph/books?isbn=0798619120

Doenges, Marilyn, Nursing Care Plans Guidelines for Individualizing Client Care Across the Life Span, 7th ed.

Doenges, Marilyn, Nurses Pocket Guide Diagnoses, Prioritized Interventions, and Rationales, 11 th ed.Videbeck, Sheila, Psychiatric Mental Health Nursing, 3

rded.


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CASE ANALYSIS


3. While hospitalized, 2 days later



Altered nutrition: less than

body requirements related to

anorexia, taste changes,

persistent nausea/vomiting,

and increased intestinal

mobility

S>Reported altered taste

sensation

>Lack of interest in food

O>Loss of weight

>Pale conjunctiva and mucous

membranes

>Poor muscle tone/ weakness

>Poor skin turgor

>Edema of extremities

>Electrolyte imbalances

GOAL:

Client will exhibit no signs or

symptoms of malnutrition by

time of discharge from

treatment (e.g., electrolytes

and blood counts will bewithin normal limits; a steady

weight gain will be

demonstrated; constipation

will be corrected; client will

exhibit increased energy in

participation in activities).

>Demonstrate behaviors,

lifestyle changes to regain

and/or maintain appropriate

weight

Dx> Determine number of

calories required to provideadequate nutrition and realistic

(according to body structureand height) weight gain.

>Strict documentation of

intake, output, and caloriecount. This information isnecessary to make an accurate

nutritional assessment andmaintain client safety.>Determine clients likes and

dislikes, and collaborate with

dietitian>Weigh client daily. Weight

loss or gain is importantassessment information.

>Monitor laboratory values,and report significant changes

to physician.Laboratory

values provide objective data

regarding nutritional status.

Tx >Provide favoritefoods. Client is more likely to

eat foods that he or she

particularly enjoys.

Fully met if:

>Client will exhibit no signs or

symptoms of malnutrition by

time of discharge

>Client has shown a slow,

progressive weight gain during

hospitalization.

>Vital signs, blood pressure,

and laboratory serum studies

are within normal limits.

>Client is able to verbalize

importance of adequate

nutrition and fluid intake.

Partially met if:

>Client has shown a slow,

progressive weight gain duringhospitalization.

>Vital signs, blood pressure,

and laboratory serum studies


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CASE ANALYSIS


>Ensure that client receives

small, frequent feedings,

including a bedtime snack,

rather than three larger

meals.Large amounts of food

may be objectionable, or even

intolerable, to the client.

>Administer vitamin and

mineral supplements as

indicated

>Stay with client during

meals to assist as needed and

to offer support and

encouragement.

Edx>>Encourage client to

increase fluid consumption

and physical exercise as

tolerated.

>Advise family members or

significant others to bring in

special foods that client

particularly enjoys.

>Explain the importance of

adequate nutrition and fluid

are within normal limits.

>Client is able to verbalize

importance of adequate

nutrition and fluid intake.

>But had not yet attained

normal weight at the time of

discharge.

Unmet if:

>Patient did not attain the goal

and did not manifest any

weight gain


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CASE ANALYSIS


intake. Client may have

inadequate or inaccurate

knowledge regarding the

contribution of good nutrition

to overall wellness.

Ref:http://www.philippinenursingdirectory.com/nursing-care-plans/imbalanced-nutrition-less-than-body-requirements/Doenges, Marilyn, Nursing Care Plans Guidelines for Individualizing Client Care Across the Life Span, 7

thed.

Doenges, Marilyn, Nurses Pocket Guide Diagnoses, Prioritized Interventions, and Rationales, 11th

ed.
http://www.philippinenursingdirectory.com/nursing-care-plans/imbalanced-nutrition-less-than-body-requirements/http://www.philippinenursingdirectory.com/nursing-care-plans/imbalanced-nutrition-less-than-body-requirements/http://www.philippinenursingdirectory.com/nursing-care-plans/imbalanced-nutrition-less-than-body-requirements/http://www.philippinenursingdirectory.com/nursing-care-plans/imbalanced-nutrition-less-than-body-requirements/


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CASE ANALYSIS


4. At home, 2 weeks after starting therapy



Risk for Infection related to

leukopenia secondary to

chemotherapy

O> immunosuppression as

seen in the laboratory results

Goal:

Client will remain free of

infection as evidenced by

temperature remaining within

normal limits.

STO:

Client will verbalize and

integrate in the lifestyle

changes interventions that

prevent infection.

Dx>Monitor vital signs to

check for infection

>Monitor laboratory results,

especially complete blood

count, white blood cell count

(WBC), differential and

absolute neutrophils

>Monitor respiratory, urinary,

mucosal and skin systems

Tx>Practice proper hand-

washing and use aseptic

technique when providing care

Edx>Instruct SO to keep

neutropenic client separate

from others

>Instruct patient to wear mask

as for self-protection

>Teach manifestations of

infection and those to reportimmediately

>Teach measures for

prevention of infection, such

as avoiding crows and not

Fully Met if: The client will

remain free of infection or

seek treatment promptly if

manifestations of infection

appear. The client will

verbalize methods that

minimize this condition

from occurring.

Partially Met if:

Patient remained free of

infection but does not

demonstrate self-care to avoid

infection

Unmet If:

Patient developed infection.


13/20

CASE ANALYSIS


cleaning fish tanks or litter

boxes

>Reinforce neutropenic diet,

and no fresh flowers in the

room.

>Instruct to avoid uncontrolled

crowds and sources of

infection; balanced diet; skin

care.

Ref: Doenges, Marilyn, Nursing Care Plans Guidelines for Individualizing Client Care Across the Life Span, 7th ed.Doenges, Marilyn, Nurses Pocket Guide Diagnoses, Prioritized Interventions, and Rationales, 11

thed.


14/20

CASE ANALYSIS


5. At home, 3 weeks after the start of chemoradiotherapy



Fatigue related to systemic

effects of radiation therapy;

Fatigue related to effects of

anemia, malnutrition,

persistent vomiting, and sleep

pattern disturbance

Secondary to:

>Build up of cellular waste

products associated with rapid

lysis of cancerous and normal

cells exposed to cytotoxic

drugs;

>difficulty resting and

sleeping associated with fear,

anxiety, and discomfort;

>tissue hypoxia associated

with anemia (a result of

malnutrition and

chemotherapy-induced bone

marrow suppression);

S> client's perception of the

severity of fatigue using a

fatigue rating scale

>verbalization of an

unremitting/ overwhelming

lack of energy

>Inability to maintain usual

routines

>Perceive need for additional

energy to accomplish routine

tasks

>Increase in rest requirements

>Disinterest in surroundings

>Decrease performance

O>lethargic

>Drowsy

The client will experience a

reduction in fatigue as

evidenced by:

a.verbalization of feelings of

increased energy

b. ability to perform usual

activities of daily living

c. Identify basis of further

fatigue and ways of

conserving energy

c.increase interest in

surroundings and ability to

concentrate

Dx>Assess for signs and

symptoms of fatigue (e.g.

verbalization of lack of energy

and inability to maintain usual

routines, lack of interest in

surroundings, decreased ability

to concentrate, lethargy)

>Determine the severity of

fatigue

Tx>Assist client to identify

personal patterns of fatigue

(e.g. time of day, after certain

activities) and to plan

activities so that times of

greatest fatigue are avoided.

>Implement measures to

reduce fatigue: perform

actions to promote rest and/or

conserve energy:

*schedule several short restperiods during the day

Fully met if:

>Patient reported improved

sense of energy

>Able to identify basis of

fatigue and individual areas of

control

>Performed ADLs and

participate at desired activities

with minimal rest periods

needed

Partially met if:

Patient reported improvedsense of energy but not yet

able to performed ADLs.

Not met if: Patient does notreport any sense of improved

energy.


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CASE ANALYSIS


>overwhelming emotional

demands associated with the

diagnosis of cancer and

treatment with

chemoradiotherapy;

>increased energy expenditure

associated with an increase in

the metabolic rate resulting

from continuous, active tumor

growth and increased levels of

certain cytokines (e.g. tumor

necrosis factor, interleukin-1);

>malnutrition;

>effects of medications used

for control of pain, nausea, and

anxiety.

*minimize environmental

activity and noise

*limit the number of visitors

and their length of stay

*assist client with self-care

activities as needed

*keep supplies and personal

articles within easy reach

*implement measures to

reduce fear and anxiety

*implement measures to

promote sleep (e.g. encourage

relaxing diversional activities

in the evening, allow client to

continue usual sleep practices

unless contraindicated, reduce

environmental stimuli,

administer prescribed

sedative-hypnotics)

*implement measures toreduce discomfort

>Promote an adequate

nutritional status encourage


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CASE ANALYSIS


client to maintain a fluid

intake of at least 2500

ml/day to promote elimination

of the by-products of cellular

breakdown

>Administer the following if

ordered for treatment of

anemia:

*folate, iron, epoetin alfa(EPO), blood transfusions (e.g.

packed red blood cells),

peripheral blood stem cell

transplantation

>Facilitate client's

psychological adjustment to

the diagnosis of cancer and the

treatment regimen and its

effects.

Edx>>Advise to increase

activity gradually as tolerated

>Advise to consult appropriatehealth care provider (e.g.

oncology nurse specialist,

physician) if signs and


17/20


18/20

CASE ANALYSIS


C. Schematic Pathophysiology of Lung Cancer

LEGEND:

Diagnostic Test

Nursing Diagnosis

Signs and symptoms

Modifiable Risk Factors

Tobacco smoke

Second hand (passive) smoke

Environmental and occupationalExposures

Dietary deficits

Respiratory diseases

Non

modifiable Risk FactorsGender

Genetics

Genetics predisposition

Carcinogenics agent

will enter the

respiratory tract

It will attack the epithelial

cells/ Lining of the lungs

Transformation of a single

epithelial cell in the

tracheobronchial alwa s

Attachment of a

carcinogen into cells DNA

causing damage

Cellular changes, abnormal

cell growth, and eventually

a malignant cell

Mutations in the K RAS

proto oncogenes will

develop cancer cells

Proto oncogenes will

turn into oncogenes

Chromosomal damage

can lead to heterozygosity

Can cause inactivation of

tumor suppressor genes


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CASE ANALYSIS


Roles of an Oncology Nurse (Focus: Treatment modality- Standards of Care)

EXPANDING THE ROLE OF THE ONCOLOGY NURSE

NURSING PRACTICE

The involvement of oncology nurses today evolves into practice in a variety of settings,

including acute-care hospitals, outpatient clinics, private oncologists offices, radiation therapy

facilities, home health care agencies and community agencies. This means that as the treatments

in oncology became increasingly complex the oncology nurse needs to be more competitive in

order to provide unique comprehensive patient care.

Aside from the more advanced way of navigating patients who were undertreated which

means earlier detection leads to earlier treatment, expanding the scope of an oncology nurse

especially in the participation in treatment modalities such as chemotherapy, radiotherapy and

hormone therapy also opens a window for bigger opportunities for the nurse to reach out andenhance the delivery of care to help cancer patients. This is somehow a way for the oncology

nurse to practice independently from the physician in terms of giving the chemodrugs. More

nurses involved in the continuity of palliative care. This study somehow provide basis for an

oncology nurse on what they can do in the extent of their service.

Furthermore, this study open our eyes on how diverse could be the field of oncology

nursing as more and more subfields emerge. Hence, the more opportunities for the oncology

nurse to upgrade their skills in delivering anti-cancer-drugs. Not only that, as they are also

pivotal in the duration of treatment because they are not only capable of giving the drugs but

they are also the ones staying with the patient, teaching the possible side-effects and how to

prevent them.

NURSING EDUCATION

In the academe, clinical instructors could also update their supervisory student nurses in

the area of the emerging fields in oncology nursing therefore entails expanding the

responsibilities and more complex procedures that the oncology nurse could do. Though, one is

not trained by those exact procedures on how they are done, as a clinical instructor, imparting

knowledge for an overview or familiarity sake is a very important role of an educator. We never

know, as a nurse educator, mentorship is also a part of our duty and we could touch and inspire

lives of the students who could later realize a calling for this career path.

Tackling on the career path development, which is a topic actually during undergrad, the

emerging subfields of oncology nursing is of concern and can be discussed to help students

realize their potentials.

NURSING RESEARCH

The reason why more and more subfields of oncology nursing emerged is the fact that

this is rooted from a research. If a study conducted sees an opportunity for the need of more

specialized oncology nurse on a particular care of a certain cancer, hence, an opening of a newsubfield for practice. So, it is needless to say that this journal may be used as additional review

of related literatures for related studies to be conducted in the future that may possibly offer

more great opportunities for oncology nurses or for the whole nursing community.

Documents

Case Analysis on Lung CA