NANDA NIC NOC Linkages

NANDA-I (North American Nursing Diagnoses Association International)

The NANDA International Classification is used for the identification of nursing diagnoses. The classification is recognized as a well established diagnosis terminology which is included in UMLS and recognized by ANA. The NANDA Nursing Diagnoses: Definition & Classification 2009-2011 includes 21 new diagnoses, 9 revised diagnoses, 6 retired diagnoses, and has a total of 202 nursing diagnoses for use in practice. Each diagnosis has a definition and the actual diagnoses include defining characteristics and related factors. Risk diagnoses include risk factors (NANDA-I, 2009). In this study, NANDA-I diagnoses are based on 155 nursing diagnoses including related factors and signs/symptoms (NANDA-I, 1999) used in the study hospital.

NOC (Nursing Outcomes Classification)

The current 4th edition Nursing Outcomes Classification has 385 outcomes with definitions, indicators, and measurement scales (1 to 5) for use at the individual, family, and community levels. It includes 58 new outcome labels and 67 revised outcomes (Moorhead et al., 2008). NOC allows nurses to follow changes in or maintenance of outcome states over time and across settings. Before providing an intervention, nurses use NOC to understand the patient’s current problems and nursing diagnoses and rate the chosen outcome to obtain a baseline rating. After providing an intervention, NOC is used to measure the outcome and determine a change score. In this study, NOC outcomes are defined as the second edition of NOC with 260 outcomes labels (Johnson, Maas, & Moorhead, 2000) as the available terminology in the study hospital

NIC (Nursing Interventions Classification)

The NIC taxonomy has 7 domains and 30 classes and 542 interventions in the fifth edition. It currently contains 34 new interventions and 77 revised interventions (Bulechek et al., 2008). Each intervention has a list of more specific activities for implementing the intervention that are selected based on the patients needs. In the study, NIC interventions from the third edition with 468 interventions were used in the study hospital as part of the nursing care planning (Dochterman & Bulechek, 2000)

NANDA NIC NOC NNN Linkages

NNN linkages provide associations between three standardized languages recognized by the American Nurses Organization: NANDA-I, NIC, and NOC. The first step in the process to link NNN is for nurses to determine a nursing diagnosis using NANDA-I diagnoses. The diagnoses that occur most frequently reflect their importance in representing an entire group of patients. After determining the nursing diagnosis, nurses consider which NOC outcomes are appropriate for the patient situation, and then choose NIC interventions that are most likely to achieve the desired outcome (Johnson, 2006).

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Understanding, Accepting, and Managing Anger in Disasters

Understanding, Accepting, and Managing Anger in Disasters. Disasters may evoke a broad spectrum of reactions in survivors, as well as responders. The cause and phase of the disaster, whether natural or human caused, may influence the intensity of emotions. Across the spectrum of reactions, anger is often one of the most understandable but most difficult to manage. Anger can be productive if channeled in the right way, but it can also become a significant obstacle to recovery, eroding physical and mental health, as well as family and community cohesion. In some instances, it can even represent a danger to mental health responders who want to assist survivors. It is important that responders and caregivers understand anger in the post-disaster environment and use effective anger management strategies.

Understanding Anger

Disasters of human intent that cause loss of innocent lives, such as terrorist attacks, may generate the most anger, while natural disasters are often considered beyond human control. However, some survivors may become intensely angry once they recognize human factors involved in a natural disaster (e.g., they may feel that the government neglected to mitigate the disaster through upgrades to the physical infrastructure or provided insufficient post-disaster resources). As a result, some survivors may project anger toward counselors, if they perceive the counselors to be representatives of government agencies. Of course, the intensity of anger can be highly variable, the targets of anger can shift or remain fixed, and targets are not mutually exclusive.

Anger can be projected toward several targets at once, and assisting survivors with anger can be tricky because it is a dynamic and ever-changing reaction. As such, we cannot suggest a universal approach to coping with anger. Some survivors feel entitled to their anger and are not quick to let it go, and some degree of anger must be allowed. Counselors should introduce anger management techniques slowly while emphasizing that anger management is actually a way of shifting control back to survivors, not just a ploy to quiet them.

Accepting Anger

Anger can be motivating in some instances and actually a powerful force in overcoming certain obstacles. But anger can be unpleasant and there is a natural tendency to see anger as a negative emotion that should be squelched. Before suggesting that anger is counterproductive in disaster recovery, responders should consider the following:

• Is the anger justified?
• Is the anger purposeful?
• Can the anger be channeled in a constructive manner?
• Does something about the target or intensity of the anger represent a danger?

Allowing ventilation, affirming the anger, and demonstrating that it can be tolerated and understood are effective first steps to de-escalating anger. But these steps must be taken safely and constructively if possible. Survivor anger, which increases or escalates over time, is common in long-term recovery projects during the “disillusionment” phase, when frustration runs high. In such instances, verbal de-escalation and relaxation techniques are useful. Anticipate escalating anger in recovery projects that survivors may perceive as delayed, “too little, too late,” or complicated by setbacks.

Managing Anger

Anger can be contagious, and even counselors can become angry, especially if they have been impacted by the disaster. This is not uncommon and should be both acknowledged in training and reinforced in team supervision. Survivors benefit most from counselors who can remain neutral and avoid being pulled into the “blame game,” yet sustain their compassion and commitment in the face of anger. Counselors who become consumed with anger are not helpful to survivors.

During the impact phase or later with populations that are hard to reach, counselors are often meeting survivors for the first time—and during one of the worst times of the survivors’ lives. Without much of a baseline knowledge of an individual, it can be difficult to assess when a survivor may cross that fine line between losing emotional control and losing physical control to the point of becoming a danger. Anger may also be an issue as people assess their losses during the disillusionment phase of disaster, especially if resources are not fully realized as expected. The following are three simple safety tips:

• Never sacrifice safety for rapport: As a disaster responder whose primary skill set is talking and listening, you know that building trust and creating an empathic connection is critical, but these should not be to one’s own detriment. You can rebuild rapport quicker than you will heal from a physical or psychological injury if a survivor becomes violent.
• Getting out or away too soon is always better than too late: Trust your instinct and intuition. If the situation or behavior feels threatening or dangerous, it probably is
• Don’t run from danger; run toward safety: Always have a plan B or exit strategy for any situation. In a home, know at least two ways out of the structure; in the community, identify safe places to go (e.g., lighted area, safe people) if the going gets rough.

In conclusion, counselors should be mindful to stay within the scope of their assigned program roles. After many years of work in the field of disaster response, one constant is true: the issues people have prior to the disaster are likely the same ones they have in the aftermath, especially those related to character and personality. Assisting a survivor in managing his or her anger is one way to help survivors cope with their response to the disaster, but if the survivor had long-standing issues with anger management prior to the disaster, these will likely continue and may even be exacerbated by the event. In some cases, these issues limit the effect of our assistance, so you may need to reconsider your definition of success. Full resolution is not always the goal

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Nursing Care Plan For Inguinal Hernia

Nursing Care Plan for Inguinal Hernia. Hernia is a protrusion or projection of an organ or organ part through an abnormal opening in the containing wall of its cavity, a hernia results. An inguinal hernia occurs when the omentum, the large or small intestine, or the bladder protrudes into the inguinal canal. In an indirect inguinal hernia, the sac protrudes through the internal inguinal ring into the inguinal canal and, in males, may descend into the scrotum. In a direct inguinal hernia, the hernial sac projects through a weakness in the abdominal wall in the area of the rectus abdominal muscle and inguinal ligament.

Hernia is classified into three types:

• Reducible, Hernias can be reducible if the hernia can be easily manipulated back into place
• Irreducible or incarcerated, this cannot usually be reduced manually because adhesions form in the hernia sac.
• Strangulated, if part of the herniated intestine becomes twisted or edematous and causing serious complications, possibly resulting in intestinal obstruction and necrosis.

Inguinal hernias can be direct which is herniation through an area of muscle weakness, in the inguinal canal, and inguinal hernias indirect herniation through the inguinal ring. Indirect hernias, the more common form, can develop at any age but are especially prevalent in infants younger than age 1. This form is three times more common in males.

Causes for Inguinal Hernia

An inguinal hernia is the result of either a congenital weakening of the abdominal wall, traumatic injury, aging, weakened abdominal muscles because of pregnancy, or from increased intra-abdominal pressure (due to heavy lifting, exertion, obesity, excessive coughing, or straining with defecation).

Inguinal hernia is a common congenital malformation that may occur in males during the seventh month of gestation. Normally, at this time, the testicle descends into the scrotum, preceded by the peritoneal sac. If the sac closes improperly, it leaves an opening through which the intestine can slip, causing a hernia.

Complications for Inguinal Hernia

Inguinal hernia may lead to incarceration or strangulation. That can interfere with normal blood flow and peristalsis, and leading to intestinal obstruction and necrosis.

Nursing Assessment Nursing care plan for Inguinal Hernia

Patient History, an infant or a child may be relatively free from symptom until she or he cries, coughs, or strains to defecate, at which time the parents note painless swelling in the inguinal area. On adult patient may occurs of pain or note bruising in the area after a period of exercise. More commonly, the patient complains of a slight bulge along the inguinal area, which is especially apparent when the patient coughs or strains. The swelling may subside on its own when the patient assumes a recumbent position or if slight manual pressure is applied externally to the area. Some patients describe a steady, aching pain, which worsens with tension and improves with hernia reduction

Physical Examination, If the patient has a large hernia, inspection may reveal an obvious swelling in the inguinal area. If he has a small hernia, the affected area may simply appear full. As part of your inspection, have the patient lie down. If the hernia disappears, it's reducible. Also ask him to perform Valsalva's maneuver; while he does so, inspect the inguinal area for characteristic bulging.

Auscultation should reveal bowel sounds. The absence of bowel sounds may indicate incarceration or strangulation. Palpation helps to determine the size of an obvious hernia. It also can disclose the presence of a hernia in a male patient.

Diagnostic tests

Commonly No specific laboratory tests are useful for the diagnosis of an inguinal hernia. Diagnosis is made on the basis of a physical examination. Although assessment findings are the cornerstone of diagnosis, suspected bowel obstruction requires X-rays and a white blood cell count, which may be elevated.

Treatment for Inguinal Hernia

The choice of therapy depends on the type of hernia. For a reducible hernia, temporary relief may result from moving the protruding organ back into place. Afterward, a truss may be applied to keep the abdominal contents from protruding through the hernial sac. Although a truss doesn't cure a hernia, the device is especially helpful for an elderly or a debilitated patient, for whom any surgery is potentially hazardous.

Herniorrhaphy is the preferred surgical treatment for infants, adults, and otherwise-healthy elderly patients. This procedure replaces hernial sac contents into the abdominal cavity and seals the opening. Another effective procedure is hernioplasty, which involves reinforcing the weakened area with steel mesh, fascia, or wire.

Strangulated or necrotic hernia requires bowel resection. Rarely, an extensive resection may require a temporary colostomy

Primary Nursing Diagnosis: Pain related to swelling and pressure

Primary nursing Outcomes: Pain, disruptive effects; pain level

Primary nursing Interventions: Analgesic administration; pain management

Nursing Outcome, Nursing Interventions, and Patient Teaching For Inguinal Hernia

Common Nursing diagnoses found on Nursing care plan for Inguinal Hernia

• Activity intolerance
• Acute pain
• Ineffective tissue perfusion: Gastro Intestinal
• Risk for infection
• Risk for injury

Nursing outcomes nursing care plans for Inguinal Hernia

• The patient will perform activities of daily living within the confines of the disease process.
• The patient will express feelings of comfort.
• The patient's bowel function will return to normal.
• The patient will remain free from signs or symptoms of infection.
• The patient will avoid complications.

Nursing interventions Nursing Care Plan For Inguinal Hernia

• Apply a truss only after a hernia has been reduced. For best results, apply it in the morning before the patient gets out of bed.
• Assess the skin daily and apply powder for protection because the truss may be irritating.
• Watch for and immediately report signs of incarceration and strangulation.
• Closely monitor vital signs and provide routine preoperative preparation. If necessary, When surgery is scheduled
• Administer I.V. fluids and analgesics for pain as ordered.
• Control fever with acetaminophen or tepid sponge baths as ordered.
• Place the patient in Trendelenburg's position to reduce pressure on the hernia site.

After surgery,

• Provide routine postoperative care.
• Don't allow the patient to cough, but do encourage deep breathing and frequent turning.
• Apply ice bags to the scrotum to reduce swelling and relieve pain; elevating the scrotum on rolled towels also reduces swelling.
• Administer analgesics as necessary.
• In males, a jock strap or suspensory bandage may be used to provide support.

Patient teaching home health guide Nursing Care Plan For Inguinal Hernia

• Explain what an inguinal hernia is and how it's usually treated.
• Explain that elective surgery is the treatment of choice and is safer than waiting until hernia complications develop, necessitating emergency surgery.
• Warn the patient that a strangulated hernia can require extensive bowel resection, involving a protracted hospital stay and, possibly, a colostomy.
• Tell the patient that immediate surgery is needed if complications occur.
• If the patient uses a truss, instruct him to bathe daily and apply liberal amounts of cornstarch or baby powder to prevent skin irritation.
• Warn against applying the truss over clothing, which reduces its effectiveness and may cause slippage. Point out that wearing a truss doesn't cure a hernia and may be uncomfortable.
• Tell the postoperative patient that he'll probably be able to return to work or school and resume all normal activities within 2 to 4 weeks.
• Explain that he or she can resume normal activities 2 to 4 weeks after surgery.
• Remind him to obtain his physician's permission before returning to work or completely resuming his normal activities.
• Before discharge, Instruct him to watch for signs of infection (oozing, tenderness, warmth, redness) at the incision site. Tell him to keep the incision clean and covered until the sutures are removed.
• Inform the postoperative patient that the risk of recurrence depends on the success of the surgery, his general health, and his lifestyle.
• Teach the patient signs and symptoms of infection: poor wound healing, wound drainage, continued incision pain, incision swelling and redness, cough, fever, and mucus production.
• Explain the importance of completion of all antibiotics. Explain the mechanism of action, side effects, and dosage recommendations of all analgesics.
• Caution the patient against lifting and straining.

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NCP Nursing Care Plan For Benign Prostatic Hyperplasia (BPH)

Although almost men older than 50 have some prostatic enlargement, with benign prostatic hyperplasia (BPH), the prostate gland enlarges sufficiently to compress the urethra and cause some overt urinary obstruction. It is the most common cause of obstruction of urine flow in men. The degree of enlargement determines whether or not bladder outflow obstruction occurs. As the urethra becomes obstructed, the muscle inside the bladder hypertrophies in an attempt to assist the bladder to force out the urine. BPH may also cause the formation of a bladder diverticulum that remains full of urine when the patient empties the bladder. Depending on the size of the enlarged prostate, the age and health of the patient, and the extent of obstruction, BPH is treated symptomatically or surgically.

Causes for Benign prostatic hyperplasia (BPH)

A link between Benign prostatic hyperplasia (BPH) and hormonal activity suggests.  As males age, production of androgenic hormones decreases, causing an imbalance in androgen and estrogen levels and high levels of dihydrotestosterone, the main prostatic intracellular androgen.

Other causes of Benign prostatic hyperplasia (BPH) include:

·         Neoplasm

·         Arteriosclerosis

·         Inflammation

·         Metabolic Imbalance

·         Nutritional disturbances.

Complications for Benign prostatic hyperplasia (BPH)

• Urinary stasis, urinary tract infection (UTI), or
• Renal calculi
• Bladder wall trabeculation
• Detrusor muscle hypertrophy
• Bladder diverticula and saccules
• Urethral stenosis
• Hydronephrosis
• Paradoxical (overflow) incontinence
• Acute or chronic renal failure
• Acute postobstructive diuresis.

Nursing Diagnosis Benign Prostatic Hyperplasia (BPH)

Nursing Diagnosis for Benign Prostatic Hyperplasia (BPH) determine by data that we collect in nursing assessment.

Nursing Assessment nursing care plans for Benign Prostatic Hyperplasia (BPH)

BPH Clinical features depend on the extent of prostatic enlargement and on the lobes affected. Patient history, generally, men with suspected BPH have a history of frequent urination, nocturia, straining to urinate, weak stream, and an incomplete emptying of the bladder

Patient usually complains of a group of symptoms known as prostatism: decreased urine stream caliber and force, an interrupted stream, urinary hesitancy, and difficulty starting urination, which results in straining and a feeling of incomplete voiding.

As the obstruction increases, the patient may report frequent urination with nocturia, dribbling, urine retention, incontinence and, possibly, hematuria.

Physical examination. Inspect and palpate the bladder for distension.

Physical examination reveals a visible midline mass above the symphysis pubis, which represents an incompletely emptied bladder. Palpation discloses a distended bladder, A digital rectal exam (DRE) reveals a rubbery enlargement of the prostate, but the degree of enlargement does not consistently correlate with the degree of urinary obstruction. Some men have enlarged prostates that extend out into soft tissue without compressing the urethra. Determine the amount of pain and discomfort that is associated with the DRE.

Diagnostic tests Benign Prostatic Hyperplasia (BPH)

Several tests help to confirm Benign Prostatic Hyperplasia (BPH) diagnosis:

·         Excretory urography may indicate urinary tract obstruction, hydronephrosis, calculi or tumors, and filling and emptying defects in the bladder.

·         Elevated blood urea nitrogen

·         Serum creatinine levels suggest impaired renal function.

·         Urinalysis and urine culture

·         Cystourethroscopy

·         Intravenous pyelography (IVP)

·         Transrectal prostatic ultrasound (TRUS)

·         A prostate-specific antigen test may be performed to rule out prostatic cancer.

Nursing diagnosis nursing care plans for  Benign Prostatic Hyperplasia (BPH)

Primary nursing diagnosis:

Urinary retention (acute or chronic) related to bladder obstruction

Common nursing diagnosis found in patient with Benign Prostatic Hyperplasia (BPH)

·         Acute pain

·         Fear/Anxiety [specify level]

·         Impaired urinary elimination

·         deficient Knowledge regarding condition,prognosis, treatment, self-care, and discharge needs

·         Risk for infection

·         Risk for injury

·         Sexual dysfunction

·         Urinary retention

Nursing care plans for Benign Prostatic Hyperplasia (BPH)

Common nursing diagnosis found in patient with Benign Prostatic Hyperplasia (BPH);  Acute pain,  Fear, Anxiety, Impaired urinary elimination,  deficient Knowledge, Risk for infection, Risk for injury, Sexual dysfunction, Urinary retention

Nursing Priorities Nursing care plans for Benign Prostatic Hyperplasia (BPH)

·         Relieve acute urinary retention.                                                

·         Promote comfort.

·         Provide information about disease process, prognosis, and treatment needs.

·         Prevent complications.

·         Help client deal with psychosocial concerns.

Sample Nursing care plans for Benign Prostatic Hyperplasia (BPH) with nursing diagnosis Urinary retention (acute or chronic)

Nursing diagnosis	Nursing interventions	Rationale	Evaluations
Urinary retention (acute or chronic) related to bladder obstruction, Decompensation of detrusor musculature	·       Review medical history for diagnoses such as prostatic hypertrophy, scarring, recurrent stone formation ·       Ask client about stress incontinence when moving, sneezing, coughing, laughing, or lifting objects. ·       Monitor vital signs ·       Observe urinary stream, size and force. ·       Prepare for and assist with urinary drainage, such as emergency cystostomy. ·       Prepare for procedures, such as the following: laser, transurethral microwave thermotherapy (TUMT), Cortherm, Prostatron, and transurethral needle ablation (TUNA), Urethral stent, Open prostate resection procedures, such as TURP	·      suggest detrusor muscle atrophy and/or chronic overdistention because of outlet obstruction ·      High urethral pressure inhibits bladder emptying or can inhibit voiding until abdominal pressure increases enough for urine to be involuntarily lost. ·      Evaluating degree of obstruction and choice of intervention. ·      May be indicated to drain bladder during acute episode ·      done to quickly create a wide open prostatic fossa, often resulting in immediate restoration of normal urine flow	·   Void in sufficient amounts with no palpable bladder distention. ·    Verbalize understanding of causative factors and appropriate interventions , Demonstrate techniques/behaviors to alleviate/prevent retention. ·   Voiding pattern normalized. .

Benign Prostatic Hyperplasia (BPH), Patient Teaching Discharge And Home Healthcare Guidelines

Patient teaching discharge and home healthcare guidelines for patient with Benign Prostatic Hyperplasia (BPH). Patient usualy  need assistance with management of therapy and catheter. Provide instructions about all medications used. Provide instructions on the correct dosage, route, action, side effects, and potential drug interactions and when to notify these to the physician, Provide information about specific procedures and tests and what to expect afterward, such as catheter, bloody urine, and bladder irritation

·         Instruct patients about the need to maintain a high fluid intake, to ensure adequate urine output.

·         Teach the patient to monitor urinary output for 4 to 6 weeks after surgery to ensure adequacy in volume of elimination combined with a decrease in volume of retention. Teach the patient to recognize the signs of UTI. Urge him to immediately report these signs to the physician because infection can worsen the obstruction.

• After the catheter is removed, the patient may experience urinary frequency, dribbling and, occasionally, hematuria. Reassure him and family members that he'll gradually regain urinary control
• Instruct the patient to follow the prescribed oral antibiotic regimen, and tell him the indications for using gentle laxatives. 

Postoperative Patient teaching

·         Provide information about sexual anatomy and function as it relates to prostatic enlargement helps client understand the implications of proposed treatments because they might affect sexual performance.

·         Encourage the patient to discuss any sexual concerns he or his partner may have after surgery with the appropriate counselors.

·         Reassure the patient that a session can be set up by the nurse or physician whenever one is indicated. Usually, the physician recommends that the patient have no sexual intercourse or masturbation for several weeks after invasive procedures.

·         Reinforce prescribed limits on activity. Warn the patient against lifting, performing strenuous exercises, and taking long automobile rides for at least 1 month after surgery because these activities increase bleeding tendency. Also caution him not to have sexual intercourse for at least several weeks after discharge

Prevention

Instruct the patient to report any difficulties with urination to the physician immediately. Explain that BPH can recur and that he should notify the physician if symptoms of urgency, frequency, difficulty initiating stream, retention, nocturia, or bladder distension recur.

• Urge the patient to seek medical care immediately if he can't void at all, if he passes bloody urine, or if develops a fever.
• Reinforce importance of medical follow-up for at least 6 months to 1 year, including rectal examination and urinalysis.

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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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