Client Assessment Database (Preoperative)

D I A G N O S T I C D I V I S I O N M AY R E P O R T

A

CTIVITY

/R

EST

•Fatigue, inability to maintain usual routine

•Dyspnea with activity

C

IRCULATION

•Swelling of extremities

•Fast heart rate

E

GO

I

NTEGRITY

•Frightened feelings, fear of outcome of surgery

•Denial of severity of condition and potential for malignancy

•Lassitude—usually in advanced stage

•Jugular vein distention (JVD), with vena caval obstruction

•Heart sounds: Pericardial rub, indicating effusion

•Tachycardia and dysrhythmias

•Clubbing of fingers

•Restlessness

•Repetitive questioning

M AY E X H I B I T

Findings depend on type, duration of cancer, and extent of metastasis.

CHAPTER 5RESPIRATORY—LUNG CANCER

D I A G N O S T I C D I V I S I O N

M AY R E P O R T

(continued)

E

^LIMINATION

•Intermittent diarrhea, due to hormonal imbalance, small cell lung cancer (SCLC)

•Increased frequency and amount of urine, due to hormonal im- balance (epidermoid tumor)

F

^OOD

/F

^LUID

•Weight loss

•Poor appetite, decreased food intake

•Difficulty swallowing

•Thirst, increased fluid intake

P

^AIN

/D

^ISCOMFORT

•Chest pain—not usually present in early stages and not always present in advanced stages

•Pain may or may not be affected by position

•Shoulder or arm pain, particularly with large cell carcinoma or adenocarcinoma

•Bone and joint pain—cartilage erosion secondary to increased growth hormones (large cell carcinoma or adenocarcinoma)

•Intermittent abdominal pain

R

^ESPIRATION

•History of smoking; occupational exposure to pollutants, industrial dusts, such as asbestos, iron oxides, coal dust, or to radioactive materials

•Mild cough or change in usual cough pattern, sputum production

•Shortness of breath

•Hoarseness or change in voice, such as with vocal cord paralysis

S

^AFETY

S

^EXUALITY

T

EACHING

/L

EARNING

•Familial risk factors—cancer, especially lung, tuberculosis

•Failure to improve

•Use of vitamins or herbal supplements, such as vitamins A, C, E; riboflavin; folic acid; ashwagandha; birch; yellow doc; milk thistle; turmeric; ginger; red clover; echinacea; astragalus;

reishi and shiitake mushrooms; zedoary

D

ISCHARGE

P

LAN

C

ONSIDERATIONS

•Assistance with transportation, medications, treatments, self-care, homemaker and maintenance tasks

ÁRefer to section at end of plan for postdischarge considerations.

•Thin, emaciated, or wasted appearance in late stages

•Edema of face or neck, chest, back, due to vena caval obstruc- tion; facial or periorbital edema, due to hormonal imbalance (SCLC)

•Glucose in urine, due to hormonal imbalance (epidermoid tumor)

•Distraction behaviors, such as restlessness, withdrawal

•Guarding and protective actions

•Dyspnea, aggravated by exertion

•Increased tactile fremitus, indicating consolidation

•Brief crackles or wheezes on inspiration or expiration

•Persistent crackles or wheezes; tracheal shift (space-occupying lesion)

•Hemoptysis

•Fever may be present, with large cell carcinoma or adenocarcinoma

•Bruising, discoloration of skin, due to hormonal imbalance (SCLC)

•Gynecomastia, due to neoplastic hormonal changes (large cell carcinoma)

•Amenorrhea, impotence, due to hormonal imbalance (SCLC)

M AY E X H I B I T

(continued)

Diagnostic Studies

T E S T

Note:These tests may be done preoperatively (not necessarily a comprehensive listing)

•Carcinoembryonic antigen (CEA, also called carcinogenic antigen): A cancer-specific immune system protein that is pres- ent in many adenocarcinomas, including lung adenocarcinoma.

•Parathyroid hormone protein-related PTHPR):Measures the release of a protein—similar to parathyroid hormone—

produced by some cancers, including all lung cancers.

•Lymphocyte count:Determines number of white blood cells present.

•Chest x-ray, posteroanterior (PA) and lateral:Evaluates organs or structures within the chest.

•Thoracic CT:An imaging method that uses x-rays to create cross-sectional pictures of the chest and upper abdomen.

•Positron emission tomography (PET) scan:Nuclear imaging scan used to evaluate and stage lung cancer.

•Magnetic resonance imaging (MRI) scan:Uses magnetic fields to produce two- or three-dimensional images of organs inside the body.

•Pulmonary function studies: including total lung capacity (TLC), functional residual capacity (FRC), and residual volume (RV):Provide information on the extent of the pul- monary abnormality and if there is air-trapping in the lungs.

•Biopsy:May be performed using forceps or needle or may be via open surgical incision. Allows for direct and microscopic examination of tissue for presence of malignant cells.

T

ESTS

T

HAT

M

AY

B

E

D

ONE

P

OSTOPERATIVELY

•Arterial blood gases (ABGs): Measures arterial oxygen (PaO₂), carbon dioxide tension (PaCO₂), and acidity (pH).

•Pulse oximetry:Noninvasive method of measuring arterial oxyhemoglobin saturation (SaO₂) via sensor placed on fingertip or earlobe.

•Complete blood count (CBC):Measures the levels of compo- nents in blood, including hemoglobin and hematocrit (Hgb/Hct), red blood cells (RBCs), white blood cells (WBCs) and their components (differential), and platelets.

Increased preoperative levels of CEA usually suggest a poor prognosis. A CEA level greater than 50 may indicate advanced-stage lung cancer.

Blood levels of PTHRP may help to distinguish lung cancer from cancer of the pleura or other diseases, is responsible for the clinical syndrome of hypercalcemia of malignancy, may stimulate proliferation of cancer cells, and is a factor in development of bone metastasis.

Lymphocytopenia or decreased level of cells can occur with sur- gical procedures and is associated with shorter survival times for clients with advanced lung cancer. Preoperative treatment with recombinant human interleukin-2 (RHIL-2) may help prevent the lymphocyte decrease.

Lung cancer is often discovered on chest x-ray. Size and location of mass can be determined. Peripheral nodules and hilar and mediastinal changes may suggest lymphadenopathy. Pleural effusions and endobronchial obstruction may be seen.

A CT scan is frequently the second step either to follow up on an abnormal chest x-ray finding or to evaluate troublesome symptoms in those with a normal chest x-ray.

Identifies occult metastatic disease in the mediastinum and dis- tant sites. More sensitive and specific than CT scan and may be used in combination with, or instead of, CT to determine tumor size and location and for staging.

Used to confirm abnormalities seen on chest x-ray, to detect early (<1 cm) lesions not visible on chest x-ray, and to assess spread to the mediastinum. Outlines shape, size, and location of lesion. May reveal erosion of ribs or vertebrae.

Volumes may be increased, indicating air-trapping, especially advanced disease. If airways are blocked by tumor, an ob- structive pattern of pulmonary disease may lead to increased or decreased FRC (Schumann, 2005).

Needle biopsy may be performed on scalene nodes, hilar lymph nodes, or pleura to establish diagnosis. Tissue biopsy of metastatic sites is used to stage disease and determine progno- sis and treatment.

Done to evaluate ventilation and acid-base status to determine treatment needs and response to therapy.

Identifies presence of anemia (low Hgb/Hct, RBCs) and potential or presence of infection (changes in numbers of WBCs and differential). Altered platelets can cause/exacerbate bleeding and bruising.

W H Y I T I S D O N E W H AT I T T E L L S M E

CHAPTER 5RESPIRATORY—LUNG CANCER

Nursing Priorities

1. Maintain or improve respiratory function.

2. Control or alleviate pain.

3. Support efforts to cope with diagnosis and situation.

4. Provide information about disease process, prognosis, and therapeutic regimen.

Discharge Goals

1. Oxygenation and ventilation adequate to meet individual activity needs.

2. Pain controlled.

3. Anxiety and fear decreased to manageable level.

4. Free of preventable complications.

5. Disease process, prognosis, and planned therapies understood.

6. Plan in place to meet needs after discharge.

N U R S I N G D I A G N O S I S : impaired Gas Exchange

May Be Related To

Ventilation-perfusion imbalance [removal of lung tissue, hypoventilation, hypovolemia]

Possibly Evidenced By Dyspnea

Restlessness Confusion

Abnormal arterial blood gases—hypoxia, hypercapnia Abnormal skin color

Desired Outcomes/Evaluation Criteria—Client Will

Respiratory Status: Gas Exchange

Demonstrate improved ventilation and adequate oxygenation of tissues by arterial blood gases (ABGs) within client’s normal range.

Be free of symptoms of respiratory distress.

NOC

ACTIONS/INTERVENTIONS RATIONALE

Respiratory Monitoring Independent

Note respiratory rate, depth, and ease of respirations. Observe for use of accessory muscles, pursed-lip breathing, or changes in skin or mucous membrane color, such as pallor and cyanosis.

Auscultate lungs for air movement and abnormal breath sounds.

Investigate restlessness and changes in mentation and level of consciousness.

Assess client response to activity. Encourage rest periods, limiting activities to client tolerance.

Note development of fever.

Airway Management

Maintain patent airway by positioning, suctioning, and use of airway adjuncts.

NIC

NIC

Respirations may be increased as a result of pain or as an initial compensatory mechanism to accommodate for loss of lung tissue. However, increased work of breathing and cyanosis may indicate increasing oxygen consumption and energy expenditures or reduced respiratory reserve, for example, in an elderly client or extensive COPD.

Consolidation and lack of air movement on operative side are normal in the client who has had a pneumonectomy; how- ever, a client who has had a lobectomy should demonstrate normal airflow in remaining lobes.

May indicate increased hypoxia or complications such as medi- astinal shift in a client who has had a pneumonectomy when accompanied by tachypnea, tachycardia, and tracheal deviation.

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.

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 obstruction impedes ventilation, impairing gas exchange. (Refer to ND: ineffective Airway Clearance.)

(continues on page 146)

ACTIONS/INTERVENTIONS

(continued)

RATIONALE

(continued)