NCP Nursing Care Plans For Lung Cancers

NCP Nursing Care Plans For Lung Cancers. Lung cancer is the uncontrolled growth of abnormal cells, which may occur in the lining of the trachea, bronchi, bronchioles, or alveoli. Ninety five percent of lung cancers are bronchogenic (arise from the epithelial lining of the bronchial tree).

Cause for Lung Cancers

Carcinogenesis, Initiation by a carcinogen (cancer-causing agent), for example, cigarette smoke, asbestos, or coal dust. Promotion by a secondary factor, for example, number of years smoking or number of cigarettes smoked. Progression, that is, the growth of pre-malignant cells and their ability to metastasize.

Lifestyle risk factors: Smoking, most common risk factor: 85% of people are or were former smokers. Others risk factor is Environmental tobacco smoke (secondhand smoke).About 3,400 lung cancer deaths in nonsmoking adults. Nonsmokers chronically exposed to secondhand smoke may have as much as a 24% increased risk for developing lung cancer.

Occupational risks: Radon, Asbestos fibers e.g. insulation and shipbuilding (7 times increased risk of death in asbestos workers & Asbestos exposure combined with cigarette smoking act synergistically to produce an increased risk of lung cancer), Arsenic (copper refining and pesticides), Beryllium (airline industry and electronics), Metals (nickel or copper), Chromium, Cadmium, Coal tar (mining), Mustard gas, Air pollution: diesel exhaust, Radiation, Tuberculosis.

Biological risks Sex/age: Males have a greater risk of lung cancer than do females, although incidence rate is declining significantly in men, from high of 102 per 100,000 in 1984 to 77.8 per 100,000 in 2002. Lung cancer incidence doubled in females from 1975 to 2000 and now has stabilized. Increased risk is associated with increasing age. 70% of all lung cancers diagnosed in individuals over the age of 65 and the number of cases diagnosed at 50 or earlier is increasing.

Family history: Lung cancer in one parent increases their children’s risk of the diagnosis of lung cancer before age 50.

Genetic predisposition: Genetic susceptibility is a contributing factor in those that develop lung cancer at a younger age. A single gene for lung cancer has not been identified. Abnormalities of p53 gene, a tumor-suppressor gene, have been suggested to be mutated in many people with lung cancer. EGFL6 gene identified as potential tumor marker.

Race: African Americans, native Hawaiians, and non-Hispanic whites have greater risk of lung cancer. Black men between the age of 35 and 64 years of age have twice the risk compared to non-Hispanic Whites.

Chronic inflammation, chronic obstructive pulmonary disease (COPD), and pulmonary fibrosis: Tuberculosis: Scarring of healthy lung tissue may lead to lung cancer development. Pulmonary fibrosis: Silica is the probable lung carcinogen. COPD: Airflow limitation results in a 6.44 times greater risk for lung cancer compared with the risk associated with absence of ventilator impairment.

Type of Lung Cancer

To categorize lung cancers visible Pathologic features on light microscopy, are used. Lung cancers are divided into two major groups, Small Cell Lung Cancer and Non–Small Cell Lung Cancer

Non-Small Cell Lung Cancer

1. Squamous cell (epidermoid forms in the lining of the bronchial tubes). Most common type of lung cancer in men. Decreasing incidence in last two decades. Typically develops in segmental bronchi, causing bronchial obstruction and regional lymph node involvement. Symptoms are related to obstruction : nonproductive cough, pneumonia, atelectasis, that is, a collapsed lung, chest pain is a late symptom associated with bulky tumor, Pancoast Tumor, or pulmonary sulcus tumor, begins in the upper portion of the lung and commonly spreads to the ribs and spine causing classic shoulder pain that radiates down the ulnar nerve distribution. Treatment: surgical resection is preferred before the development of metastatic disease, chemotherapy and radiation therapy to decrease the incidence of recurrence.
2. Adenocarcinoma. Most common form in Unites States, Increasing incidence in females. Occurs in non smokers. adenocarcinoma develops in the periphery of the lungs and frequently metastasizes to brain, bone, and liver. Symptoms: no symptoms with small peripheral lesions, Identifi ed by routine chest radiograph/CT scan. Treatment: surgical resection and chemotherapy and radiation therapy to decrease the incidence of recurrence.
3. Bronchioalveolar (BAC). Form near the lung’s air sacs. BAC may have abnormal gene in their tumor cells. Targeted chemotherapy treatment appears to be effective.
4. Large cell. Large cell: 10% of all lung cancer cases. Bulky peripheral tumor. Metastasizing to brain, bone, adrenal glands, or liver. Symptoms related to obstruction or metastatic spread pneumonitis and pleural effusions. Treatment: surgical resection (limited because of the often aggressive course of this tumor type) and chemotherapy and radiation therapy (palliative role to minimize symptoms of advanced disease).

Small-Cell Lung Cancer

Patients with SCLC often have widespread disease at the time of diagnosis. Rapid clinical deterioration in patients with chest masses often indicates SCLC

1. Oat cell carcinoma Oat cell carcinoma: 13% of all lung cancers. Most aggressive type, greater tendency to metastasize than Non-Small Cell Lung Cancer Strongly related to cigarette smoking often occurs within the mainstem bronchi and segmental bronchi; 80% of cases have hilar and mediastinal node involvement. Symptoms: Paraneoplastic syndrome: syndrome of inappropriate antidiuretic hormone (SIADH), Hyponatremia, fluid retention, weakness, and fatigue, Ectopic adrenocorticotropic hormone (ACTH) production, Hypokalemia, hyponatremia, hyperglycemia, lethargy, and confusion. Treatment for Oat cell carcinoma, Surgery rarely indicated even in those with limited stage disease because of the need for immediate systemic therapy and chemotherapy and radiation therapy offers the best hope for prolonged survival and quality of life. Majority of the patients respond to chemotherapy and radiation therapy but recurrence rate is very high. Two-thirds of patients demonstrate evidence of extensive disease at the time of diagnosis.
2. Non-Bronchogenic Carcinomas. Undifferentiated non-small cell lung cancer (NSCLC). Non-bronchogenic carcinomas undifferientated non-small cell lung cancer (NSCLC) : <5% of all lung cancers combined: Mesothelioma a rare tumor of the parietal pleura, Mesothelioma is another rare type of cancer which affects the covering of the lung (the pleura). It is often caused by exposure to asbestos, bronchial adenoma (carcinoid), fibrosarcoma.

Staging of Lung Cancer

Knowing the stage of Lung Cancer is important because treatment is often decided according to the stage of a Lung cancer. TNM staging system. TNM staging takes the following factors into account. The size of the Lung Cancer (T). Whether Lung Cancer cells have spread into the lymph nodes (N) whether the Lung Cancer has spread anywhere else in the body - secondary cancer or metastases (M)

Stage of Lung cancer

TNM (Tumor, Nodes, Metastases) system of staging

TNM Stage of Lung cancer Description:

Primary tumor (T)

• TX; Primary tumor cannot be assessed, or tumor proven by the presence of malignant cells in sputum or bronchial washings but not visualized by imaging or bronchoscopy.
• T0 : No evidence of primary tumor
• Tis : Carcinoma in situ
• T1 : Tumor 3 cm in greatest dimension, surrounded by lung or visceral pleura, without bronchoscopic evidence of invasion more proximal than the lobar bronchus (i.e., not in the main bronchus)
• T2: Tumor with any of the following features of size or extent: 3 cm in greatest dimension. Involves main bronchus, 2 cm distal to the carina Invades the visceral pleura Associated with atelectasis or obstructive pneumonitis that extends to the hilar region but does not involve the entire lung.
• T3 : Tumor of any size that directly invades any of the following: chest wall (including superior sulcus tumors), diaphragm, mediastinum pleura, parietal pericardium; or tumor in the main bronchus, 2 cm distal to the carina, but without involvement of the carina; or associated atelectasis or obstructive pneumonitis of the entire lung
• T4: Tumor of any size that invades any of the following: mediastinum, heart, great vessels, trachea, esophagus, vertebral body, carina; or tumor with a malignant pleural or pericardial effusion, b or with satellite tumor nodule(s) within the ipsilateral primary-tumor lobe of the lung

Regional lymph nodes (N)

• NX Regional lymph nodes cannot be assessed
• N0 No regional lymph node metastasis
• N1 Metastasis to ipsilateral peribronchial and/or ipsilateral hilar lymph nodes, and intrapulmonary nodes involved by direct extension of the primary tumor
• N2 Metastasis to ipsilateral mediastinal and/or subcarinal lymph node(s)
• N3 Metastasis to contralateral mediastinal, contralateral hilar, ipsilateral, or contralateral scalene, or supraclavicular lymph node(s)

Distant Metastasis (M)

• MX Presence of distant metastasis cannot be assessed
• M0 No distant metastasis
• M1 Distant metastasis present

Stage grouping (TNM subsets):

• Stage IA (T1 N0 M0), IB (T2 N0 M0). Most common form of early lung cancer located only in the lungs. Detected on routine chest X-ray in patients who present for unrelated medical condition or routine examination. Treatment-surgical resection.
• Stage IIA (T1 N1 M0), IIB (T2 N1 M0, T3 N0 M0). Tumors in the lung and lymph nodes (hilar and bronchopulmonary nodes). Treatment-surgical resection and adjuvant radiation or chemotherapy, or both. Induction chemotherapy before surgery is being investigated. Patients with significant co-morbid disease surgery may not be an option.
• Stage IIIA (T3 N1 M0, T1 N2 M0, T2 N2 M0, T3 N2 M0) Cancer in the lung and lymph nodes on the same side of the chest. T3 tumors involving the main stem bronchi produce hemoptysis, Dyspnea, wheezing, atelectasis, and post obstructive pneumonia. T3 tumors involving the pericardium or diaphragm may be symptomatic but those involving the chest wall usually cause pain. Nodal disease is often asymptomatic, if extensive nodal disease may cause compression of the proximal airways and superior vena cava syndrome. Treatment—selected cases surgical resection (T3NO-1), commonly multi-modality therapy with chemotherapy being primary form of treatment; multiple trials of combined chemotherapy, radiation with or without surgery are under investigation.
• Stage IIIB (T4 N0 M0, T4 N1 M0, T4 N2 M0, T1 N3 M0, T2 N3 M0, T3 N3 M0, T4 N3 M0) Cancer has spread to the lymph nodes on the opposite side of the chest. T4 tumors invade the mediastinum structures, and/or malignant pleural effusions. N3—metastases. Treatment—chemotherapy and radiation therapy; in rare exceptions, surgery may be considered.
• Stage IV (Any T Any N M1) Evidence of metastatic disease. Treatment often palliative (to relieve symptoms). Clinical trials may offer some survival benefit.

Complications of Lung Cancer

Like many other neoplasm disease Complications of Lung Cancer occurs when lung cancer metastasized to other organ, outside the Lung. Disease progression and metastasis cause various complications. Early stage and localized disease may be asymptomatic. Symptoms are often medically treated and attributed to conditions such as bronchitis, pneumonia, and chronic obstructive pulmonary disease. Symptoms: cough & wheezing, increased sputum production, hemoptysis, Dyspnea, pneumonia, pleural effusions.

Advanced disease predominant at time of diagnosis related to tumor growth and compression of adjacent structures. When the primary tumor spreads to intrathoracic structures, complications may include tracheal obstruction; esophageal compression with dysphagia; phrenic nerve paralysis with hemidiaphragm elevation and dyspnea; sympathetic nerve paralysis with Horner’s syndrome with ptosis, miosis, hemifacial anhydrosis, clubbing, hypertrophic osteoarthropathy, bone pain, fatigue, dysphagia from esophageal compression, wheezing or stridor, phrenic nerve paralysis with elevated hemidiaphragm, arrhythmias and heart failure (from pericardial involvement), hypoxia related to lymphangitic spread, superior vena cava syndrome (swelling of the face, neck and upper extremities and related to compression of blood vessels in the neck and upper thorax.

Symptoms: chronic cough, Dyspnea, weight loss, increased sputum production, hemoptysis, hoarseness (involvement of the laryngeal nerve), pleural effusions and atelectasis, chronic pain, pain over the shoulder and medial scapula, arm pain with or without muscle wasting along ulnar distribution,

Lung cancer usually cause breathing or heart problems such as:

• Pleural effusion

• Pericardial effusion

• Coughing up large amounts of bloody sputum.

• Collapse of a lung (pneumothorax).

• Blockage of the airway (bronchial obstruction).

• Recurrent infections, such as pneumonia.

Other complications are anorexia and weight loss, sometimes leading to cachexia, digital clubbing, and hypertrophic osteoarthropathy. Endocrine syndromes may involve production of hormones and hormone precursors.

Extra thoracic spread of disease: adrenal glands (50%), liver (30%), brain (20%), bone (20%), kidneys (15%), scalene lymph nodes. Prognosis remains poor and has improved very slightly despite medical advances: <14% combined 5-year survival rate.

Nursing Diagnosis for Lung Cancer

To determine nursing diagnosis for Lung cancer, Nurses use Nursing assessment as tools for collecting data from the patients. Its included patient history, physical psychosocial assessment, and result from Diagnostic tests.

Nursing Assessment Nursing care Plans for Lung Cancer

Patient History

Establish a history of persistent cough, chest pain, Dyspnea, weight loss, or hemoptysis. Smoking history, other risk factors (family history, occupational risks), associated diseases (COPD, tuberculosis, and emphysema), symptom description and onset. Ask if the patient has experienced a change in normal respiratory patterns or hoarseness. Some patients initially report pneumonia, bronchitis, and epigastria pain, symptoms of brain metastasis, arm or shoulder pain, or swelling of the upper body. Ask if the sputum has changed color, especially to a bloody, rusty, or purulent hue. Elicit a history of exposure to risk factors by determining if the patient has been exposed to industrial or air pollutants. Check the patient’s family history for incidence of lung cancer

Physical examination

The clinical findings of lung cancer may be localized to the lung or may result from the regional or distant spread of the disease. Lung auscultation, respiratory rate and depth, palpitation of supraclavicular area for tumor or lymphatic involvement or both, clubbing, nicotine stains to skin, hair, teeth. Lung cancer clinical manifestations depend on the type and location of the tumor. Because the early stages of this disease usually produce no symptoms, it is most often diagnosed when the disease is at an advanced stage. In 10% to 20% of patients, lung cancer is diagnosed without any symptoms, usually from an abnormal finding on a routine chest x-ray.

Auscultation may reveal a wheeze if partial bronchial obstruction has occurred. Auscultate for decreased breath sounds, rales, or rhonchi. Note signs of an airway obstruction, such as extreme shortness of breath, the use of accessory muscles, abnormal retractions, and stridor. Monitor the patient for oxygenation problems, such as increased heart rate, decreased blood pressure, or an increased duskiness of the oral mucous membranes. Metastases to the mediastinum lymph nodes may involve the laryngeal nerve and may lead to hoarseness and vocal cord paralysis. The superior vena cava may become occluded with enlarged lymph nodes and cause superior vena cava syndrome; note edema of the face, neck, upper extremities, and thorax.

Psychosocial

The patient is faced with a psychological adjustment to the diagnosis of a chronic illness that frequently results in death. Patient undergoes major lifestyle changes as a result of the physical side effects of cancer and its treatment. Interpersonal, social, and work role relationships change. Evaluate the patient for evidence of altered moods such as depression or anxiety, and assess the patient’s coping mechanisms and support system.

Diagnostic tests For Lung Cancer

1. Chest radiographs plain anterior-posterior and lateral views not reliable to find lung tumors in their earliest stage.
2. Chest Computed Tomography (CT) three-dimensional image of the lungs and lymph nodes (can detect tumors as small as 5 millimeters). CT is only about 80% accurate in predicting mediastinum node involvement.
3. Spiral computed tomography of the chest.
4. Magnetic Resonance Imaging (MRI) 92% accuracy in the diagnosis of mediastinum invasion.
5. Positron Emission Tomography (PET) scan is based upon increased glucose metabolism in cancer cells. The PET scan uses a glucose analogue radiopharmaceutical to identify increased glycolysis in tumor tissues. The PET scan is a highly sensitive test in the diagnosis and staging of lung cancer.
6. Bronchoscopic detection of tumor auto fluorescence could improve cure rates in selected groups at high-risk.
7. Sputum cytology
8. Percutaneous transthoracic needle biopsy
9. Fine needle aspiration or biopsy
10. Bronchoscopy.
11. Mediastinoscopy to evaluate lymph node involvement.
12. Scalene node biopsy (evaluate lymph node involvement)
13. experimental Photodynamic therapy; An injection of a light-sensitive agent with uptake by cancer cells, followed by exposure to a laser light within 24 to 48 hours, will result in fluorescence of cancer cells or cell death. Especially helpful in identifying developing cancer cells or “carcinoma in-situ.” Also used to determine the extent of disease and the response to treatment.
14. Assessment of distant metastasis: Abdominal CT (identify adrenal or liver metastasis), Head CT, MRI (brain), Bone scan; Thoracentesis (detect malignant cells in the pleural fluid).

Nursing Diagnosis for Lung Cancer

Common Nursing diagnosis found in nursing care plans for patient with Lung Cancer:

1. Impaired gas exchange related to Removal of lung tissue, altered oxygen supply.
2. Ineffective Airway Clearance May be related to : Increased amount or viscosity of secretions, Restricted chest movement, pain, Fatigue, weakness
3. Acute Pain May be related to: Surgical incision, tissue trauma, and disruption of intercostals nerves, Presence of chest tube, Cancer invasion of pleura, chest wall
4. Fear/Anxiety [specify level] May be related to: Situational crises, Threat to or change in health status, Perceived threat of death.
5. Deficient Knowledge [Learning Need] regarding condition, treatment, prognosis, self-care, and discharge needs. May be related to : Lack of exposure, unfamiliarity with information or resources, Information misinterpretation, Lack of recall

Common Treatment Methods of Lung Cancer

A common treatment method of Lung Cancer is Surgery, chemotherapy and radiotherapy is all classified as a treatment for lung cancer. Knowing the stage of Lung Cancer is important because treatment is often decided according to the stage of a Lung cancer. Lung cancer accounts for more deaths than prostate, breast, and colon cancer combined. The 1-year survival rate remains approximately 41%, and the 5-year survival rate is 15%. Only 16% of lung cancers are found at an early, localized stage, when the 5-year survival rate is 49%. The survival rate for lung cancer has not improved over the last 10 years.

Common treatment methods of Lung Cancer

Surgery Treatment for Lung Cancer

The treatment of choice for non-small cell lung cancer, Stage IA, IB, IIA, IIB, and selected cases of stage IIIA : lobectomy (removal of a lobe of the lung), pneumonectomy (removal of one lung), wedge resection or segmentectomy for patients with inadequate pulmonary reserve who cannot tolerate lobectomy, VATS (Video Assisted Thoroscopic Surgery), palliative surgery. Before surgery patient must know the risk factor from Lung Cancer Surgery; Risks from lung cancer surgery include damage to structures in or near the lungs, general risks related to surgery, and risks from general anesthesia

Patient education before surgery: patient understands surgical procedure, incision, placement of chest tubes; smoking cessation before surgery to reduce pulmonary complications pain control; bronchodilators, coughing and deep-breathing exercises, early ambulation after surgery.

After surgery : assess respiratory function (respiratory rate, level of dyspnea, use of accessory muscles, and arterial blood gases); monitor chest tube drainage and air leaks ; monitor oxygen saturation at rest and ambulation ; assess pain control ; chest physical therapy (bronchial drainage positions, deep breathing, coughing) ; early ambulation ; monitor for atrial arrhythmias ; discharge planning and home care arrangements.

Chemotherapy Treatment for Lung Cancer

Researchers are continually looking at different ways of combining new and old drugs for advanced non-small cell lung cancer.

Chemotherapy Treatment for Non-Small Cell Lung Cancer

1. Customize treatment; Erlotinib (Tarceva) for people whose tumors have epidermal growth factor receptors, a genetic mutation. Gefitinib (Iressa) effective in people whose lung tumors have similar genetic mutations.
2. Targeted treatments for advanced non-small cell lung cancer; Sunitinib (Sutent) works by cutting off blood supply and blockingnthe cancer cells their ability to grow. Sorafenib (Nexavar) suppresses receptors for vascular endothelial growth factor platelet derived growth factor—plays a critical role in the growth of blood vessels that feed the cancer (angiogensis).
3. Combined methods are the treatment of choice for selected cases of stage IIIA and IIIB; Cispatin, Paclitaxel and Gemcitabine, Gemcitabine and Vinorelbine, Carboplatin and Paclitaxel and radiation, Cisplatin and Vinblastine and radiation
4. Stage IV; Carboplatin and Paclitaxel, Carboplatin and Gemcitabine, Cisplatin and Vinorelbine, Docetaxel and Gemcitabine, Pemetrexed, Chemotherapy combined with Cetuximab (Erbitux): Cetuximab binds to epidermal growth factor receptors (EGFR), preventing a series of reactions in the cell that lead to lung cancer.
5. Progression of disease: Single-agent Docetaxel, Gemcitabine, Paclitaxel
6. Investigational New treatment approaches are being investigated all the time. Mage-A3 vaccine and non-small cell lung cancer, Bortezomib (Velcade) proteasome inhibitors destroys cancer cells

Chemotherapy Treatment for Small-Cell Lung Cancer

1. Limited-stage disease; Pulmonary resection stage I or stage II, Etoposide and Cisplatin and Radiation, Etoposide and Carboplatin
2. Extensive stage disease: Etoposide and Carboplatin +/− Paclitaxel, Adriamycin, Cyclophosphamide
3. Investigational: Vaccine-autologous dendritic cell-adenovirus p53

Chemotherapy treatment Complications, Myelosuppression (infection, anemia, bleeding), nephrotoxicity, nausea and vomiting, mucositis (inflammation of the mucous membranes), fatigue, SIADH and hyponatremia, hypotension, anaphylaxis, alopecia (hair loss), neurotoxicity (peripheral neuropathies, central nervous system toxicity), cardiomyopathy, arrhythmias, congestive heart failure, myocardial infarction, pneumonitis or pulmonary fibrosis, taste changes.

Patient education (chemotherapy): chemotherapeutic agents, treatment schedule, adverse effects of drugs.

Radiation therapy Treatment for Lung Cancer

1. External beam radiotherapy used as an adjunct to surgery to decrease tumor size, to cure patients considered inoperable for medical or pathologic reasons, or to decrease symptoms. Radiation after surgery: to improve resectability of tumor & to sterilize microscopic disease. Radiation after surgery: to treat disease confined to one hemi thorax with hilar or mediastinum nodal metastasis & to reduce local recurrence (if positive surgical margins exist). Prophylactic cranial irradiation: limited disease small-cell lung cancer to reduce reoccurrence in CNS.
2. Brachytherapy placement of radioactive sources (seeds or catheter) directly into or adjacent to a tumor. Intraoperative: reduce local recurrence. Symptom palliation (relief of pain from bone metastases, hemoptysis, superior vena cave syndrome, airway obstruction).

Complications of radiation therapy: Dyspnea, cough, initial increase in mucus production, and then dry cough, fatigue, skin erythema, esophagitis and dysphagia, pneumonitis, lung fibrosis.

Patient education: radiation therapy: indelible markings, treatment schedule, site-specific adverse effects (within treatment field).

Treatment alternatives

Neoadjuvant is therapy given before the primary therapy to improve effectiveness (e.g., chemotherapy or radiation before surgery). Adjuvant treatments are equally beneficial and often given concurrently or immediately following one another to maximize effectiveness (e.g., surgery and adjuvant chemotherapy after surgery), multimodality is therapy that combines more than one method of treatment (e.g. concurrent chemotherapy and radiation, such as, adjuvant and Neoadjuvant)

Home care considerations

After lung surgery: smoking cessation, control of incision pain, wound care, breathing exercises and coughing, pursed lip breathing exercises, maintain fluid intake, maintaining your nutrition, resume activity, regaining arm and shoulder function.

During and after radiation therapy: monitor side effects of radiation therapy and report any change in.

Symptoms: Dyspnea, fatigue is common lasting 4–6 weeks after therapy, good nutrition, liquid diet supplement during periods of esophagitis, avoid wearing tight clothes, skin care.

During and after chemotherapy, advise patients:

1. To identify all treatment related side effects and report changes
2. Fatigue may last weeks to months
3. To plan their day, and allow for periods of rest
4. Try activities such as yoga, exercise, meditation, and guided imagery
5. Keep a diary and document symptoms, activity level, nutrition, treatments, and emotions
6. To monitor effectiveness of pain medications
7. To monitor for any signs of infection, such as an increased temperature, redness or swelling, and that the latter symptoms may not be present during weeks of impaired immunity following chemotherapy administration
8. Monitor weight change and appetite
9. Nutritional supplements

Pulmonary rehabilitation programs: exercise strengthening, breathing exercises, walking program, nebulizers/aerosol medication delivery, disease specific instruction and support. Support groups: Lung Cancer specific, Better Breathers Club a support group sponsored by the American Lung Association for patients with chronic lung disease. Hospice: dignified dying, pain management, end of life issues, patient/family support.

NCP Nursing Care Plan For Lung Cancer

NCP Nursing care Plan for Lung Cancer. Common Nursing Diagnosis found in nursing care plan for Lung Cancer: Impaired gas exchange related to Removal of lung tissue, altered oxygen supply, Ineffective Airway Clearance May be related to Increased amount or viscosity of secretions, Restricted chest movement, pain, Fatigue, weakness, Acute Pain May be related to Surgical incision, tissue trauma, and disruption of intercostals nerves, Presence of chest tube, Cancer invasion of pleura, chest wall, Fear/Anxiety specify level May be related to: Situational crises, Threat to or change in health status, Perceived threat of death, Deficient Knowledge [Learning Need] regarding condition, treatment, prognosis, self-care, and discharge needs. May be related to: Lack of exposure, unfamiliarity with information or resources, Information misinterpretation, Lack of recall

Sample Nursing care Plan for Lung Cancer with interventions and rationale

Nursing diagnosis Impaired gas exchange

May be related to:

• Removal of lung tissue (Surgery Treatment for Lung Cancer)

• Altered oxygen supply hypoventilation

• Decreased oxygen-carrying capacity of blood (blood loss).

Nursing outcomes and evaluation criteria client will: Respiratory status: gas exchange, Demonstrate improved ventilation and adequate oxygenation of tissues by arterial blood gases (ABGs) within client normal range, be free of symptoms of respiratory distress, the patient will maintain adequate ventilation. The patient will maintain a patent airway.

Nursing Interventions Nursing care Plan for Lung Cancer Nursing diagnosis Impaired gas exchange:

Respiratory Management:

1. Note respiratory rate, depth, and ease of respirations. Observe for use of accessory muscles, pursed-lip breathing, or changes in skin or mucous membrane Rationale Respirations may be increased as a result of compensatory mechanism to accommodate for loss of lung tissue or pain.
2. Auscultate lungs for air movement and abnormal breath sounds. Rationale Consolidation and lack of air movement on operative side are normal in the client who has had a pneumonectomy; but in a client who has had a lobectomy should demonstrate normal airflow in remaining lobes.
3. Investigate restlessness and changes in mentation and level of consciousness. Rationale May indicate increased hypoxia or complications such as mediastinum shift in a client who has had a pneumonectomy when accompanied by tachypnea, tachycardia, and tracheal deviation.
4. Assess client response to activity. Encourage rest periods, limiting activities to client tolerance. Rationale Increased oxygen consumption and demand and stress of surgery may result in increased Dyspnea and changes in vital signs with activity; however, early mobilization is desired to help prevent pulmonary complications and to obtain and maintain respiratory and circulatory efficiency. Adequate rest balanced with activity can prevent respiratory compromise.
5. Note development of fever. Rationale Fever within the first 24 hours after surgery is frequently due to atelectasis. Temperature elevation within postoperative day 5 to 10 usually indicates an infection, such as wound or systemic.

Airway Management:

1. Maintain patent airway by positioning, suctioning, and use of airway adjuncts. Rationale Airway obstruction impedes ventilation, impairing gas exchange. (Refer to ND: ineffective Airway Clearance).
2. Reposition frequently, placing client in sitting and supine to side positions. Rationale Maximizes lung expansion and drainage of secretions.
3. Avoid positioning client with a pneumonectomy on the operative side. Rationale Research shows that positioning clients following lung surgery with their “good lung down” maximizes oxygenation by using gravity to enhance blood flow to the healthy lung, thus creating the best possible match between ventilation and perfusion.
4. Encourage and assist with deep-breathing exercises and pursed lip breathing, as appropriate. Rationale Promotes maximal ventilation and oxygenation and reduces or prevents atelectasis.
5. Administer supplemental oxygen via nasal cannula, partial rebreathing mask, or high-humidity face mask, as indicated. Rationale Maximizes available oxygen, especially while ventilation is reduced because of anesthetic, depression, or pain, and during period of compensatory physiological shift of circulation to remaining functional alveolar units.
6. Assist with and encourage use of incentive spirometer. Rationale Prevents or reduces atelectasis and promotes reexpansion of small airways.
7. Monitor and graph ABGs and pulse oximetry readings. Note hemoglobin (Hgb) levels. Rationale Decreasing PaO2 or increasing PaCO2 may indicate need for ventilatory support. Significant blood loss results in decreased oxygen-carrying capacity, reducing PaO2.

Tube Care Chest:

1. Maintain patency of chest drainage system following lobectomy and segmental wedge resection procedures. Rationale Drains fluid from pleural cavity to promote re expansion of remaining lung segments.
2. Note changes in amount or type of chest tube drainage. Rationale Bloody drainage should decrease in amount and change to a more serous composition as recovery progresses. A sudden increase in amount of bloody drainage or return to frank bleeding suggests thoracic bleeding or a hemothorax, sudden cessation suggests blockage of tube, requiring further evaluation and intervention.
3. Observe for presence of bubbling in water-seal chamber. Rationale Air leaks appearing immediately postoperatively are not uncommon, especially following lobectomy or segmental resection; however, this should diminish as healing progresses. Prolonged or new leaks require evaluation to identify problems in client versus a problem in the drainage system.

Nursing diagnosis Ineffective Airway Clearance

May be related to:

• Increased amount or viscosity of secretions

• Restricted chest movement, pain

• Fatigue, weakness

Nursing Outcomes and Evaluation Criteria Client Will:

• Respiratory Status: Airway Patency

• Demonstrate patent airway, with fluid secretions easily expectorated, clear breath sounds, and noiseless respirations.

Nursing Interventions nursing care Plan for Lung Cancer Nursing diagnosis Ineffective Airway Clearance

1. Auscultate chest for character of breath sounds and presence of secretions. Rationale: Noisy respirations, rhonchi, and wheezes are indicative of retained secretions or airway obstruction.
2. Assist client with and provide instruction in effective deep breathing, coughing in upright position (sitting), and splinting of incision. Rationale Upright position favors maximal lung expansion, and splinting improves force of cough effort to mobilize and remove secretions. Splinting may be done by nurse placing hands anteriorly and posterior over chest wall and by client, with pillows, as strength improves.
3. Observe amount and character of sputum and aspirated secretions. Investigate changes, as indicated. Rationale Increased amounts of colorless (or blood-streaked) or watery secretions are normal initially and should decrease as recovery progresses. Presence of thick, tenacious, bloody, or purulent sputum suggests development of secondary problems for example, dehydration, pulmonary edema, local hemorrhage, or infection that require correction or treatment.
4. Suction if cough is weak or breathe sounds not cleared by cough effort. Avoid deep endotracheal and nasotracheal suctioning in client who has had pneumonectomy if possible. Rationale Suctioning increases risk of hypoxemia and mucosal damage. Deep tracheal suctioning is generally contraindicated. If suctioning is unavoidable, it should be done gently and only to induce effective coughing.
5. Encourage oral fluid intake, within cardiac tolerance. Rationale Adequate hydration aids in keeping secretions loose and enhances expectoration.
6. Assess for pain and discomfort and medicate on a routine basis and before breathing exercises. Rationale Encourages client to move, cough more effectively, and breathe more deeply to prevent respiratory insufficiency.
7. Provide and assist client with incentive spirometer and postural drainage and percussion, as indicated. Rationale Improves lung expansion and ventilation and facilitates removal of secretions. Note: Postural drainage may be contraindicated in some clients, and, in any event, must be performed cautiously to prevent respiratory embarrassment and incision discomfort.
8. Use humidified oxygen and ultrasonic nebulizer. Provide additional fluids intravenously (IV), as indicated. Rationale Maximal hydration helps promote expectoration. Impaired oral intake necessitates IV supplementation to maintain hydration.
9. Administer bronchodilators, expectorants, and analgesics, as indicated. Rationale Relieves bronchospasm to improve airflow. Expectorants increase mucus production and liquefy and reduce viscosity facilitating removal of secretions.

Nursing Diagnosis Acute Pain

May be related to:

• Surgical incision, tissue trauma, and disruption of intercostals nerves

• Presence of chest tubes

• Cancer invasion to pleura or chest wall

Nursing Outcomes and Evaluation Criteria Client Will:

• Pain Level

• Report pain relieved or controlled.

• The patient will express feelings of comfort and decreased pain

• Appear relaxed and sleep or rest appropriately.

• Participate in desired as well as needed activities.

Nursing Interventions and rationale nursing care Plan for Lung Cancer with nursing diagnosis Acute Pain

1. Ask client about pain. Determine pain location and characteristics. Have client rate intensity on a scale of 0 to 10. Rationale Helpful in evaluating cancer related pain symptoms, which may involve viscera, nerve, or bone tissue. Use of rating scale aids client in assessing level of pain and provides tool for evaluating effectiveness of analgesics, enhancing client control of pain.
2. Assess client verbal and nonverbal pain cues. Rationale Discrepancy between verbal and nonverbal cues may provide clues to degree of pain and need for and effectiveness of interventions.
3. Note possible pathophysiological and psychological causes of pain. Rationale Fear, distress, anxiety, and grief can impair ability to cope. Posterolateral incision is more uncomfortable for client than an anterolateral incision. Discomfort can greatly increase with the presence of chest tubes.
4. Evaluate effectiveness of pain control. Encourage sufficient medication to manage pain; change medication or time span as appropriate. Rationale Pain perception and pain relief are subjective, thus pain management is best left to client’s discretion. If client is unable to provide input, the nurse should observe physiological and nonverbal signs of pain and administer medications on a regular basis.
5. Encourage verbalization of feelings about the pain. Rationale Fears and concerns can increase muscle tension and lower threshold of pain perception.
6. Provide comfort measures such as frequent changes of position, back rubs, and support with pillows. Encourage use of relaxation techniques including visualization, guided imagery, and appropriate Diversional activities. Rationale Promotes relaxation and redirects attention. Relieves discomfort and therapeutic effects of analgesia.
7. Schedule rest periods, provide quiet environment. Rationale Decreases fatigue and conserves energy, enhancing coping abilities.
8. Assist with self care activities, breathing, arm exercises, and ambulation. Rationale Prevents undue fatigue and incision strain. Encouragement and physical assistance and support may be needed for some time before client is able or confident enough to perform these activities because of pain or fear of pain.
9. Assist with patient-controlled analgesia (PCA) or analgesia through epidural catheter. Administer intermittent analgesics routinely, as indicated, especially 45 to 60 minutes before respiratory treatments, and deep-breathing and coughing exercises. Rationale Maintaining a constant drug level avoids cyclic periods of pain, aids in muscle healing, and improves respiratory function and emotional comfort and coping.

Nursing Diagnosis Fear/Anxiety [specify level]

May be related to:

• Situational crises

• Threat to or change in health status

• Perceived threat of death

Nursing Outcomes and Evaluation Criteria Client Will:

• Fear Self-Control or Anxiety Self-Control

• Acknowledge and discuss fears and concerns.

• Demonstrate appropriate range of feelings and appear relaxed and resting appropriately.

• Verbalize accurate knowledge of situation.

• Report beginning use of individually appropriate coping strategies.

Nursing Interventions and rationale nursing care Plan for Lung Cancer with nursing diagnosis Fear/Anxiety:

1. Evaluate client and significant other (SO) level of understanding of diagnosis. Rationale Client and SO are hearing and assimilating new information that includes changes in self-image and lifestyle. Understanding perceptions of those involved sets the tone for individualizing care and provides information necessary for choosing appropriate interventions.
2. Acknowledge reality of client’s fears and concerns and encourage expression of feelings. Rationale Support may enable client to begin exploring and dealing with the reality of cancer and its treatment. Client may need time to identify feelings and even more time to begin to express them.
3. Provide opportunity for questions and answer them honestly. Be sure that client and care providers have the same understanding of terms used. Rationale Establishes trust and reduces misperceptions or misinterpretation of information.
4. Accept, but do not reinforce, client’s denial of the situation. Rationale When extreme denial or anxiety is interfering with progress of recovery, the issues facing client need to be explained and resolutions explored.
5. Note comments and behaviors indicative of beginning acceptance or use of effective strategies to deal with situation. Rationale Fear and anxiety will diminish as client begins to accept and deal positively with reality. Indicator of client’s readiness to accept responsibility for participation in recovery and to “resume life.”
6. Involve client and SO in care planning. Provide time to prepare for events and treatments. Rationale May help restore some feeling of control and independence to client who feels powerless in dealing with diagnosis and treatment.
7. Provide for client’s physical comfort. Rationale It is difficult to deal with emotional issues when experiencing extreme or persistent physical discomfort.

Nursing Diagnosis Deficient Knowledge Learning Need regarding condition, treatment, prognosis, self-care, and discharge needs

Related to:

• Lack of exposure, unfamiliarity with information or resources

• Information misinterpretation

• Lack of recall

Nursing Outcomes and Evaluation Criteria Disease Process and Treatment Regimen Client Will:

• Verbalize understanding of ramifications of diagnosis, prognosis, and possible complications.

• Participate in learning process Knowledge of the Disease Process.

• Verbalize understanding of therapeutic regimen.

• Correctly perform necessary procedures and explain reasons for the actions.

• Initiate necessary lifestyle changes.

Nursing Interventions and rationale nursing care Plan for Lung Cancer with nursing diagnosis Deficient Knowledge Learning Need regarding condition, treatment, prognosis, self-care, and discharge needs:

1. Discuss diagnosis, current and planned therapies, and expected outcomes. Rationale Provides individually specific information, creating knowledge base for subsequent learning regarding home management. Radiation or chemotherapy may follow surgical intervention, and information is essential to enable the client and SO to make informed decisions.
2. Reinforce surgeon’s explanation of particular surgical procedure, providing diagram as appropriate. Incorporate this information into discussion about short- and long-term recovery expectations. Rationale Length of rehabilitation and prognosis depend on type of surgical procedure, preoperative physical condition, and duration and degree of complications.
3. Discuss necessity of planning for follow-up care before discharge. Rationale Follow-up assessment of respiratory status and general health is imperative to assure optimal recovery. Also provides opportunity to readdress concerns or questions at a less stressful time.
4. Identify signs and symptoms requiring medical evaluations, such as changes in appearance of incision, development of respiratory difficulty, fever, increased chest pain, and changes in appearance of sputum. Rationale Early detection and timely intervention may prevent or minimize complications. Stress importance of avoiding exposure to smoke, air pollution, and contact with individuals with upper respiratory infections (URIs).
5. Review nutritional and fluid needs. Suggest increasing protein and use of high-calorie snacks as appropriate. Rationale Meeting cellular energy requirements and maintaining good circulating volume for tissue perfusion facilitate tissue regeneration and healing process.
6. Identify individually appropriate community resources, such as American Cancer Society, visiting nurse, social services, and home care. Rationale Agencies such as these offer a broad range of services that can be tailored to provide support and meet individual needs.
7. Help client determine activity tolerance and set goals. Rationale Weakness and fatigue should decrease as lung heals and respiratory function improves during recovery period, especially if cancer was completely removed. If cancer is advanced, it is emotionally helpful for client to be able to set realistic activity goals to achieve optimal independence.
8. Evaluate availability and adequacy of support system(s) and necessity for assistance in self-care and home management. Rationale General Weakness and activity limitations may reduce individual’s ability to meet own needs.
9. Encourage alternating rest periods with activity and light tasks with heavy tasks. Stress avoidance of heavy lifting and isometric or strenuous upper body exercise. Reinforce physician’s time limitations about lifting. Rationale Generalized weakness and fatigue are usual in the early recovery period but should diminish as respiratory function improves and healing progresses. Rest and sleep enhance coping abilities, reduce nervousness (common in this phase), and promote healing. Note: Strenuous use of arms can place undue stress on incision because chest muscles may be weaker than normal for 3 to 6 months following surgery.
10. Recommend stopping any activity that causes undue fatigue or increased shortness of breath. Rationale Exhaustion aggravates respiratory insufficiency.
11. Instruct and provide rationale for arm and shoulder exercises. Have client or SO demonstrate exercises. Encourage following graded increase in number and intensity of routine repetitions. Rationale Simple arm circles and lifting arms over the head or out to the affected side are initiated on the first or second postoperative day to restore normal range of motion (ROM) of shoulder and to prevent ankylosis of the affected shoulder.
12. Encourage inspection of incisions. Review expectations for healing with client. Rationale Healing begins immediately, but complete healing takes time. As healing progresses, incision lines may appear dry with crusty scabs. Underlying tissue may look bruised and feel tense, warm, and lumpy (resolving hematoma).
13. Instruct client and SO to watch for and report places in incision that do not heal or reopening of healed incision, any drainage (bloody or purulent), and localized area of swelling with redness or increased pain that is hot to touch. Rationale Signs and symptoms indicating failure to heal, development of complications requiring further medical evaluation and intervention.
14. Suggest wearing soft cotton shirts and loose-fitting clothing; cover portion of incision with pad, as indicated, and leave incision open to air as much as possible. Rationale Reduces suture line irritation and pressure from clothing. Leaving incisions open to air promotes healing process and may reduce risk of infection.
15. Shower in warm water, washing incision gently. Avoid tub baths until approved by physician. Rationale Keeps incision clean and promotes circulation and healing. Note: “Climbing” out of tub requires use of arms and pectoral muscles, which can put undue stress on incision.
16. Support incision with butterfly bandages as needed when sutures and staples are removed. Rationale Aids in maintaining approximation of wound edges to promote healing.

Patient Teaching, Discharge And Home Healthcare Guidelines for patient with Lung Cancer

Patient Teaching, Discharge and Home Healthcare Guidelines for patient with Lung Cancer usually divide in to before surgery and post surgery. Be sure the patient understands any medication prescribed, including dosage, route, action, and side effects. Teach the patient about medical procedure before surgery and post surgery. Teach the patient how to maximize her or his respiratory effort.

Patient Teaching, Discharge and Home Healthcare Guidelines for Lung Cancer

• Before surgery, supplement and reinforce what the physician has told the patient about the disease and the operation.
• Teach the patient about postoperative procedures and equipment. Discuss urinary catheterization, chest tubes, endotracheal tubes, dressing changes, and I.V. therapy.
• If the patient is receiving chemotherapy or radiation therapy, explain possible adverse effects of these treatments. Teach him ways to avoid complications, such as infection. Also review reportable adverse effects.
• Educate high-risk patients about ways to reduce their chances of developing lung cancer or recurrent cancer.
• Refer smokers to local branches of the American Cancer Society or Smokenders. Provide information about group therapy, individual counseling, and hypnosis.
• Urge all heavy smokers older than age 40 to have a chest X-ray annually and cytologic sputum analysis every 6 months. Also encourage patients who have recurring or chronic respiratory tract infections, chronic lung disease, or a nagging or changing cough to seek prompt medical evaluation.

Patient Teaching, Discharge and Home Healthcare Guidelines for Lung Cancer post Surgery

• Provide the patient with the names, addresses, and phone numbers of support groups, such as the American Cancer Society, the National Cancer Institute, the local hospice, the Alliance for Lung Cancer Advocacy, Support & Education (ALCASE), and the Visiting Nurses Association
• Teach the patient to recognize the signs and symptoms of infection at the incision site, including redness, warmth, swelling, and drainage. Explain the need to contact the physician immediately
• Warn an outpatient to avoid tight clothing, sunburn, and harsh ointments on his chest. Teach him exercises to prevent shoulder stiffness.
• Teach him how to cough and breathe deeply from the diaphragm and how to perform range-of-motion exercises. Reassure him that analgesics and proper positioning will help to control postoperative pain.

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What Is the Central Membrane of the Cochlea?

What Is the Central Membrane of the Cochlea? The cochlea is a long coiled tube, with three channels divided by two thin membranes. The top tube is the scala vestibuli, which is connected to the oval window. The bottom tube is the scala tympani, which is connected to the round window. The middle tube is the scala media, which contains the Organ of Corti. The Organ of Corti sits on the basilar membrane, which forms the division between the scalae media and tympani.

Figure 12.3 illustrates a cross section through the cochlea. The three scalae (vestibuli, media, tympani) are cut in several places as they spiral around a central core. The cochlea makes 2-1/2 turns in the human (hence the 5 cuts in midline cross section). The tightly coiled shape gives the cochlea its name, which means snail in Greek (as in conch shell). As explained in Tonotopic Organization, low frequency sounds stimulate the base of the cochlea, whereas high frequency sounds stimulate the apex. This feature is depicted in the animation of Figure 12.3 with neural impulses (having colors from red to blue representing low to high frequencies, respectively) emerging from different turns of the cochlea. The activity in Figure 12.3 would be generated by white noise that has all frequencies at equal amplitudes. The moving dots are meant to indicate afferent action potentials. Low frequencies are transduced at the apex of the cochlea and are represented by red dots. High frequencies are transduced at base of the cochlea and are represented by blue dots. A consequence of this arrangement is that low frequencies are found in the central core of the cochlear nerve, with high frequencies on the outside.

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5 Human Basic Needs

Man according to the Basic Needs Human Body Composition. Our bodies, based on its physical form composition, can be divided into 5 parts. If we’re listing from below to above the sequence are the 5 parts are: feet, genitals, abdomen, chest and head. In terms of medical or biological, may share the above not appropriate in accordance with their respective biological functions, but the authors proposed a new idea of human basic needs of 5 based on the division of the body structure into 5 sections, the authors interpret as security needs, sex, economic, spiritual and innovation, thus becomes more easily understood.

Not just from our side as a human being, in terms of interpersonal relationships in a social community, non-profit organizations profit, even to any state institution, in compliance to this Basic Human Needs, each function as individuals, organizations, companies and even countries in meet basic needs, can be understood more easily. Each of the previously mentioned requirements, as in humanistiknya Maslow’s psychological theory, the 5 basic needs must be met even in a linear fashion, like rungs in a pyramid structure, which must be climbed step-by-step.

But there are fundamental differences in Maslow’s theory with a new paradigm of the writer to say, namely that 5 Basic Human Needs in this new paradigm, all centered on the needs of number 3, namely economic needs. This economic needs must be met first (though not necessarily completely), before other needs, because the economy needs is like gasoline in cars. Without gasoline, the car will not be able to move. Similarly, people without food and drink, could not meet the needs of others.

1. Safety Requirements (Safety Needs), the need for protection or safety against the danger of violence, after the economic needs, the relative (not necessarily completely) fulfilled.
2. Needs Sex (Sex Needs), the sexual drive needs an outlet, for those who are mature biological functions. Fundamental error & fatal Sigmund Freud (1856-1939) was the discussion focused psychology that all human KDM bersala of this sexual needs. We can not blame those of Freud’s view, if we can understand the social circumstances of his era, which was taboo to talk about sex. Freud’s view is rebellion to the people of his era.
3. Economy Needs (Economical Needs) arising from a man born and died. Without fulfilling the primary requirement for this physical body, a human being could not meet the basic needs of others. These needs must be met before other needs. Food and beverage needs are basic needs, which became the center of human physical needs.
4. Spiritual Needs (Spiritual Needs), the need for respect for self respect, status, attention and acceptance of others, which appears when the three previous requirements were met. Also the need for affiliation, friendship and giving and receiving love / appreciated by / of / by others in the social life of society. Although according to Maslow’s social needs & prestige rarely be satisfied, according to author-4 the need to subject humanity is started, the belief in the power of the more Essence of everything from him, real life goals are, and the object of education is supposed to do. In the history of the prophets and great men, although other needs has not met, but spiritual needs are met, so they can continue to survive his nation to educate people, even written in gold ink in human history. So, in addition to the human body needs based on the stomach, the spiritual needs of people based in the heart, the chest cavity.
5. Needs Innovation (Innovation Needs) is the last requirement when the four other requirements above are met, which can encourage a person’s behavior can enhance the ability to work with the mind to optimize the function to innovate, one of the advantages provided specifically for the human creator. The authors point to the need of innovation is the need to optimize the function of reason to think, research and develop new knowledge to make it easier for him in an attempt to meet the basic needs of man. So R & D and technology, innovative technology, will not be able to run optimally, if the other 4 of the human needs are not met first.

In the course of history, the need for the 3 and 4 often were reduced (united) to just 1 level of demand, the economy needs it or just spiritual needs, which makes human life be entirely secular groups seeking false happiness in the world alone, or group becomes an expert zuhud with Sufism, clerical, and only the pursuit of happiness in akherat course. The best thing is that the group does not deny one of them, but those who can balance the needs of those 2, the stomach needs (economic, physical) and the need for liver

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Urinary Tract Infection UTI

Urinary Tract Infection UTI occurs when bacteria enter and multiply in tne normally sterile urinary tract. This causes inflammation, which can result in small amounts of blood, pus (white blood cells that fight infection), and bacteria in the urine. This can also cause pain with urination (called dysuria), a sense of needing to urinate frequently, a feeling of urgency, and sometimes cramping in the lower abdomen. The infection can involve the urethra (the short tube from the bladder to the outside of the body), the bladder, sometimes the ureters (longer tubes connecting the bladder and kidneys), and occasionally the kidneys. If the kidneys are involved you may have flank pain, fever, and chills.

What causes Urinary Tract Infection UTI?

Most of these infections-85-95%-are causes by bacteria that are normally present in the intestine. The vaginal area also has certain bacteria present normally. Because women have a short urethra which opens near the vagina, bacteria can enter the bladder relatively easily.

Urine needs to be examined under a microscope for white blood cells, red blood cells, and bacteria. Sometimes with recurrent infections, a culture is grown to determine which organisms are causing the infection. Sensitivity studies determine which antibiotics are effective for those organisms. After treatment, a urinalysis or a colony count is often done to make sure the infection is cleared. This can decrease the possibility of a mild, undetected infection which can lead to an early recurrence of a more severe bladder infection or might spread to the kidneys.

Treatment For Urinary Tract Infection UTI

• Urinary tract infections are treated with antibiotics.
• Drinking a lot of liquids (an eight-ounce glass per hour) helps wash out the urinary tract.
• Cranberry juice, plums, or apricot juice can help by creating a more acid environment in which bacteria cannot grow as easily. NOTE: This is not a substitute for treatment with antibiotics.
• Avoid caffeine (common in coffee, tea, and cola drinks), because it irritates the bladder.
• Hot baths can alleviate discomfort.
• Rest helps conserve energy for healing the infection.

Prevention For Urinary Tract Infection UTI?

• Drink plenty of liquids to keep the urinary tract flushed. Concentrated, stagnant urine can allow bacteria to multiply.
• Always urinate when you feel the need. Overfilling the bladder can cause irritation and microscopic tears in the bladder wall,which lead to infection.
• Wash your hands before you urinate, as well as after. To avoid spreading bacteria, wipe from front to back after urination or bowel movements.
• Urinate before and after sexual intercourse to flush bacteria away.
• Caffeine and alcohol are irritating to the bladder and should be avoided.
• Keeping the vaginal area dry will make it harder for bacteria to grow. Wearing cotton underwear and avoid confining clothes can help keep the area dry.

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Postpartum Complications

Despite the normalcy of childbirth, complications may arise that will have detrimental effects on the postpartum client. These include postpartum hemorrhage, thrombophlebitis, infections (including mastitis, endometritis, and urinary tract infections), and postpartum depression. Healthcare providers working with postpartum clients must have a clear understanding of these complications, including the symptoms, nursing interventions, and treatment.

Postpartum Hemorrhage (PPH)

Postpartum hemorrhage is one of the leading causes of death among postpartum clients. Postpartum hemorrhage refers to a blood loss of more than 500 mL after a vaginal birth and more than 1000 mL after a C-section. Postpartum hemorrhage is categorized as early or late. Early refers to a hemorrhage occurring within the first 24 hours after birth, while late refers to a hemorrhage occurring after 24 hours.

RISK FACTORS

Every postpartum client has the potential to hemorrhage after delivery. However, some clients have attributes that place them at higher risk for postpartum hemorrhage. These risk factors include:

• Multiple parity
• Multi-fetal pregnancy
• Macrosomia
• Prolonged or precipitous labor
• Labor induction
• Vacuum or forceps delivery
• Lacerations
• Stillbirth
• Placenta previa
• Use of certain medications (eg, magnesium sulfate)
• Mechanical factors, such as a full bladder

CAUSES AND INTERVENTIONS

Early postpartum hemorrhage is often caused by uterine atony. With uterine atony, there is a failure of the uterine muscles to contract properly, thereby inhibiting the healing of blood vessels at the site of placental attachment. The blood vessels continue to bleed until the uterine muscles contract. Signs of uterine atony include a boggy uterus, a fundus that is higher than expected upon palpation, and excessive lochia.

If the fundus is not firm (boggy), there are several nursing interventions that can alleviate the problem:

• Massage the uterine fundus.
• Express blood clots only if the uterus is firmly contracted, otherwise, uterine inversion and severe hemorrhage can occur.
• Encourage the client to void, or catheterize as needed.
• Administer prescribed medications, such as Pitocin, Ergonovine, Methergine, or Hemabate to assist the uterus in contracting. (Methergine can cause an elevation in blood pressure and should not be used with hypertensive clients.)

The nurse must report a PPH immediately and prepare for the insertion of a large-bore intravenous catheter, if one is not already present, and the administration of intravenous fluids and oxygen. A large-bore intravenous catheter is inserted to allow possible administration of blood products. The nurse should assess continually for bleeding, changes in vital signs, and oxygen saturation. The client's legs may also be elevated "to a 20° to 30° angle to increase venous return" (Leifer, 2005). Clients and their families will need nursing support during a PPH as it can be quite a disconcerting experience.

Early postpartum hemorrhage can also be caused by damage to the birth canal during labor and birth. If an early PPH is due to trauma to the birth canal, such as a hematoma, an extension of a perineal incision, or an improperly sutured laceration, clients may exhibit one or more of the following symptoms: a contracted uterus with excessive lochia, bright red lochia, a constant trickle of blood from the vagina, severe pain (possibly from a hematoma), or shock.

In the case of an early PPH caused by damage to the birth canal, surgical repair is usually necessary. In the case of hematoma formation, surgical incision, evacuation of blood clots, and ligation of the bleeding blood vessel may be necessary. However, in the case of a small hematoma, observation and application of ice or alternating hot and cold applications may be all that is necessary (Leifer, 2005).

Late postpartum hemorrhage is often caused by subinvolution of the uterus or by retained placental fragments that prevent the uterus from contracting. In the case of retained placental fragments, clots develop around the retained fragments and hemorrhaging can occur days later when the clots are shed. The certified nurse-midwife or physician is responsible for examining the placenta after delivery and ensuring that it is intact; therefore, a late PPH is usually preventable. Clients with placenta accreta (an abnormally deep attachment of the placenta) or when providers attempt to extract the placenta prior to uterine wall separation are at higher risk for a late PPH.

Assessment and manual expression of placental fragments by the physician or nurse-midwife can often alleviate the problem; however, surgical intervention, such as a dilation and evacuation (D&E) may be necessary. With subinvolution and a late PPH, fundal massage, in addition to medications (Pitocin, Ergonovine) and the previously mentioned interventions for early PPH, may be used to minimize bleeding.

HYPOVOLEMIC SHOCK

A sequela of PPH is hypovolemic shock. Under normal circumstances, postpartal clients are able to withstand blood loss during the postpartum period as a result of increased blood volume during pregnancy. However, in the presence of a PPH, hypovolemic shock can occur and cause severe organ damage and even death if untreated. Often tachycardia is the first sign of hypovolemic shock. The blood pressure usually decreases and the respiratory rate increases. The skin becomes cool and pale initially and then cold and clammy. Clients may also become anxious, agitated, and restless as blood loss starts to affect the brain. Hypovolemic shock can be stopped by stopping blood loss. These clients will also require oxygen (usually 8–10 mL via face mask), IV fluids, and possibly blood products. This is a very serious situation and nurses must be prepared to assist in this life-threatening emergency.

Thrombophlebitis

Clients can suffer from thrombophlebitis as a result of venous stasis and the normal hypercoagulability state of the postpartum period. Thrombophlebitis is an inflammation of the blood vessel wall in which a blood clot forms and causes problems in the superficial or deep veins of the lower extremities or pelvis. All postpartum clients are at risk. However, certain risk factors predispose some clients to developing thrombophlebitis. These risk factors include varicose veins, clotting disorders, delivering via C-section, diabetes mellitus, smoking, obesity, prolonged sitting or standing, and advanced maternal age.

The blood clot that develops in thrombophlebitis can lead to a life-threatening pulmonary embolism as a result of the clot detaching from the vein wall and blocking the pulmonary artery. The major signs of pulmonary embolism include dyspnea and chest pain.In monitoring postpartum clients for the development or presence of thrombophlebitis, nurses should assess for the presence of hot, red, painful, or edematous areas on the lower extremities or groin area. An elevated temperature may also be present. As previously mentioned, it is currently contraindicated to assess for a thrombophlebitis by eliciting a Homan's sign.

Interventions to treat thrombophlebitis depend on the severity of the thrombosis. Usually, for superficial thrombosis, analgesics, bed rest, and elevation of the affected limb is enough to alleviate the problem. However, in the presence of a DVT, anticoagulants may be necessary. In addition to use of compression stockings and warm, moist heat applications, clients should be instructed to keep their legs elevated and uncrossed. These clients are typically allowed to ambulate only after symptoms subside.

Infections

Postpartum infections are infections accompanied by a temperature of 38° C or higher on two separate occasions where no other explanation is responsible for the elevation in temperature. Postpartum clients should be carefully monitored for signs and symptoms of infection during this period. Common infections that may occur during the postpartum period include mastitis, endometritis, wound infections, and urinary tract infections.

MASTITIS

Mastitis is a breast infection caused by Staphylococcus aureus. S. aureus is found on the hands and can also be in the mouths of infants. Bacteria can enter through cracked nipples caused by improper latch-on during breastfeeding. Mastitis can develop due to blocked milk ducts and milk stasis in the breastfeeding clients. Blocked milk ducts and milk stasis occurs as a result of improper latching and inadequate breast emptying.

It is crucial that postpartum nurses teach breastfeeding clients proper latch techniques. Additionally, nurses must stress that clients feed infants regularly and allow the breast to empty completely. Breastfeeding clients should also be encouraged to avoid missing feedings and allowing the breast to become engorged.The classic symptom of mastitis is a unilateral mass in the breast accompanied by pain and redness. Often these clients experience a low-grade fever, chills, and general malaise. If untreated, a breast abscess may develop. Treatment for mastitis typically involves antibiotic therapy and regular breastfeeding or pumping the breast. Nurses can encourage these clients to apply cold or warm compresses to ease discomfort and to take analgesics as needed. Mastitis usually resolves quickly as long as clients continue to breastfeed or pump regularly.

ENDOMETRITIS

Endometritis is an infection of the uterus characterized by uterine subinvolution, infection, abdominal cramps, and purulent, foul-smelling lochia. It is caused by the bacteria normally present in the uterus and cervix, such as E. coli and group B streptococcus. Manual removal of the placenta, multiple vaginal examinations during labor, C-sections, premature rupture of members, and internal fetal and/or uterine monitoring predispose clients to developing endometritis.

In addition to cramping and foul-smelling lochia, clients with endometritis typically have a fever, chills, general malaise, and may exhibit tachycardia. Blood cultures to identify the causative organism are typically done and white blood cell (WBC) counts are monitored. However, it is important to remember that the white blood cell count is normally elevated after delivery for a short period; continued monitoring of the WBC count is required in identifying endometritis. Endometritis is usually treated with intravenous antibiotics and rest.

WOUNDS

Wound infections are infections that occur at wound sites. Commonly affected wound sites during the postpartum period include the perineum, where lacerations and episiotomies occur, and C-section incisions. As with all infections, every client is at risk.

Postpartum clients with wound infections typically have wounds that exhibit redness, warmth, poor wound approximation, tenderness, and pain. If untreated, these clients may develop a fever and other symptoms of an infection, such as malaise. As with endometritis, blood cultures may be obtained to isolate the causative organism. Antibiotics will typically be administered and drainage of the wound may be necessary.

Dressing changes using normal saline will aid in the healing process. Clients should be taught about proper handwashing and encouraged to maintain adequate fluid intake and increase protein intake to assist in wound healing. Wound infections can be intensely painful, especially in the perineum. Therefore, the nurse should assist these clients in managing pain through the use of analgesics and positioning.

URINARY TRACT INFECTIONS (UTIs)

Urinary tract infections are common during the postpartum period. The client's urethra and bladder is often traumatized during labor and birth due to intermittent catheterizations and the pressure of the infant as it passes through the birth canal. Additionally, the bladder and urethra loose tone after delivery, making the retention of urine and urinary stasis common. The risk of developing a UTI is high. Clients may also develop a UTI due to frequent catheterization while in labor or the placement of a Foley catheter, which frequently remains in place for several hours or days after delivery.

Clients with urinary tract infections often complain of frequent and/or painful urination as well as flank pain. A low-grade fever and hematuria may also be present. Urinary tract infections are treated with antibiotics, but it is important that these clients drink adequate fluids to flush bacteria out of the system. (Additionally, it has been suggested that cranberry juice is useful in preventing urinary tract infections due to acidifying the urine and preventing bacteria from attaching to the bladder walls; however, there is great debate over this issue.)

Postpartum Depression

Postpartum depression is a serious and debilitating depression that affects many women throughout the world. According to Blum (2007), "There are no specific, generally accepted criteria for time after delivery for a depression to be considered a postpartum depression, but typically these depressions occur within the first nine months after the baby's birth, often within the initial weeks or months." Symptoms typically include sadness, crying, insomnia, decreased appetite, withdrawal, and sometimes suicidal ideation or the desire to harm the infant. Additionally, clients may present with somatic symptoms, such as "headaches, diarrhea, constipation, severe anxiety, feeling as though they are jumping out of their skin, and/or just not feeling like themselves" (Driscoll, 2006).

It is the responsibility of nurses to assess postpartum clients for signs and symptoms of postpartum depression. Various assessment tools are available, including the Edinburgh Postnatal Depression Scale (EPDS) and the Postpartum Depression Screening Scale (PDSS). These tools are quick and provide a simple way to assess clients while at the hospital, at home during postpartum home visits, and during postpartum follow-up visits. These tools can also be used to assess maternal clients at pediatric follow-up visits.

After screening and assessment, clients who are at risk for developing (or who are suffering from) postpartum depression can be referred to the appropriate healthcare provider for follow-up and treatment. According to Lowdermilk and Perry (2006), symptoms of postpartum depression rarely disappear without outside help; therefore, it is imperative to appropriately assess and refer clients suffering from this type of depression.

Postpartum depression is usually treated with counseling and medication. Nurses can support these clients in the healing process at follow-up appointments and during home visits. Driscoll (2006) recommends that nurses help clients and their families understand postpartum depression and assist them in exploring the spiritual aspects of their suffering as an aid in the healing process. Additionally, nurses should encourage these clients to get adequate nutrition, rest, relaxation, and exercise (Driscoll, 2006).

DISCHARGE INSTRUCTIONS

Postpartum clients and their families should be instructed to call the healthcare provider if the client has any of the following:

• Fever
• Foul-smelling lochia
• Large blood clots or bleeding that saturates a pad in one hour
• Discharge or severe pain from incisions
• Hot, red, painful areas on the breasts or legs
• Bleeding and/or severe pain in the nipples
• Severe headaches and/or blurred vision
• Chest pain and/or dyspnea without exertion
• Frequent, painful urination
• Signs of depression

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Nurses Role in Proper Care and Prevention of Wound Infection

In the mature population, chronic wounds and pressure ulcers are a significant cause of mortality (McGuiness & Rice, 2009). Over 32,000 adult patients die annually in the United States because of improper wound treatments in the hospital (Cohen, 2007); consequently, costing hospitals to up to $9.3 billion in added expenses (Franz, Steed, & Robson, 2007). When a client receives a wound and it is not treated properly, infection may become a complication and can increase the risk of mortality in an individual up to 55% (Salcido, 2009). As a result of the increasing rates of death due to improper wound management and infections, nurses must be knowledgeable about wound care and pressure ulcers, and how to prevent infection.

Why are nurses having trouble with providing the appropriate care for client’s chronic wounds? Contributing factors to delayed wound healing is due to lack of knowledge on caring for wounds, inadequate supervision by the nurse, and due to the client’s socioeconomic status. According to McGuiness in The Management of Chronic Wounds, “Inappropriate product selection [and]...extended periods of time between assessments… delay healing” (2009, p. 37). If the nurse is unable to take care of the client’s wounds appropriately, the client’s wounds do not heal accordingly.

Prevention

When the nurse receives the client, two main steps need to always be applied. First, the nurse needs to identify and evaluate the risks of the client to gain pressure ulcers or worsening of treatable wounds. At admission, a head to toe assessment should be instigated. Inspect and palpate for changes in skin integrity, texture, temperature, turgor, moisture, color changes, and edema (Blaney, 2010). Document the observation and reassess skin integrity and changes in condition every shift or according to facility policies to track the progress of the injury.

The next step is when evidence-based practices are put into place. Start by minimizing pressure to decrease the start of pressure ulcers. A turning schedule should be implemented (normally every two hours), and using pillows to minimize pressure on bony prominences. According to research, if the turning schedule is used correctly than there could be an 87% reduction of pressure sores (Lyder, & Ayaller, 2008). By using a turning schedule and by continually monitoring the wounds, the nurse will help decrease the incidence of pressure sores.

Adequate hydration and nutrition should also be kept up. Offering small, frequent meals of high-protein, high calorie diet with zinc and vitamin C should be encouraged. Having a proper diet will increase the wound’s healing time. If the patient eats foods that are high in fat, sugar, and salts the healing time of the wounds will decrease. Therefore, it is important that the patient is encouraged to eat a nutritious meal.

As the client lies in bed, the head of the bed should be no more than 30 degrees, unless contraindicated. If the client needs to turn, and can do so without assistance, encourage the client to lift themselves when they are moving instead of sliding around on the bed. When the patient slides on the bed, it produces friction and can create chronic wounds and pressure ulcers (Blaney, 2010). By encouraging the client to lift themselves, the decrease of sliding on the bed will prevent wounds from getting worst and may increase the chance of faster healing. Any potential barrier that could hinder the client would be their socioeconomic status and the deficient knowledge and lack of teaching skills.

Protective Dressings

For each wound, whether it is from pressure ulcers, surgeries, or accidents, the appropriate choice of dressing or therapy and skin protectant must be used. There are many non-adherent dressings available for wound management. They include Urgotul™ and Tegapore ™ (McGuiness, 2009), which can all be used safely with no trauma or pain. They also do not need to be changed regularly. For wounds with high levels of discharge absorbent foam dressings will be required. Nurses need to make sure that “care must be taken… that dressings are adequately sealed preferably without adherence to friable skin to prevent leakage…” (McGuiness, 2009). When the proper dressings and healing techniques are used this helps decrease the wound healing time. However, if the client is unable to pay or have the proper insurances then they might not get the assistance they need. Also, if the nurse does not know how to properly address wounds or pressure ulcers, their lack of knowledge could decrease the chances of the wound to heal.

Preventing Infection

The environment of a wound is an ideal home for bacterial invasion which makes it necessary for the client to take antibiotics. The nurse needs to emphasize to the client the importance of taking the antibiotic as instructed by the doctor. There have been many concerns of antibiotic resistance by the bacteria due to prolonged illnesses and deaths. This antibiotic resistant bacterium is also popularly known as MRSA. By having the client finish the antibiotic the chances of creating antibiotic resistant bacteria diminishes.

Because of the risk of new infections, different hygiene measures should also be considered for the various transmission routes. Not only should dressings and antiseptics should be used, but another way to slow down the spread of infection is for the nurse and other care providers to wash their hands or use hand sanitizers. “At the University of Geneva, a hospital-wide program promoting hand hygiene helped lower the hospital-acquired infection rate from 17 percent to 10 percent between 1994 and 1998” (Jain, 2008). These important steps are key components to be done after contact with an infected client or before caring for a vulnerable one. Any problems that would hinder the client are the lack of knowledge and teachings of the nurse to teach the importance of finishing the antibiotic and the client’s socioeconomic status where they might not be able to afford to buy the medication to prevent infection.

Potential Barriers

Two potential barriers for all these problems is socioeconomic and insufficient knowledge by the nurse. The client’s socioeconomic status may prohibit them from getting the proper help due to lack of income, transportation, or unable to find or obtain adequate health insurance. However, the nurse can help prevent high costs by having sufficient knowledge in prevention and educating the client about wound care and prevention.

To give thorough care for the wound, nurses need to make sure they are doing proper cleansing of the wound, controlling any signs and symptoms of infection, and ensuring the treatment of the underlying condition (McGuiness & Rice, 2009). When the nurse is incapable to properly address the wound and unable to assess the damaged area appropriately and within reasonable time, the damaged area is unable to continue through the normal stages of healing. Once wounds become infected, they are incapable to heal and are caught in a constant inflammatory condition because of a breakdown of the healing process in the tissues (Menke, Menke, Boardman, & Diegelmann, 2008). When there is a breakdown of the healing process, McGuiness (2009) asserts, the “result is often an increased shear and friction on wounds, inappropriate exudates control and the facilitation of infection” (p. 37). It is for these reasons that it is essential for nurses to gain an education and understanding in prevention of pressure ulcers and knowledge in wound management to decrease the occurrence of chronic wounds.

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