Question

Read the following scenario. Complete a care plan with at least 2 NANDA approved nursing diagnoses, at least 3 interventions for each diagnosis, and the rationale behind all. Please refer to the article posted in the Updates to review the NANDA approved diagnoses and how and why they are utilized.

Mr. Emery was admitted to the hospital to have a lung biopsy and resection. Following surgery, he is transferred to the surgical unit with two right pleural chest tubes connected to pleur-evac systems with 20 cm of dry suction. Chest tube A is anterior and chest tube B is lower and posterior.

Orders Include: Up to the chair as tolerated Cough and deep breath 10 times per hour Change dressing daily IV of Lactated ringers at 75 ml/hour Regular diet

Answer 1

Ans)

Impaired Gas Exchange: Excess or deficit in oxygenation and/or carbon dioxide elimination at the alveolar-capillary membrane related to:

- Removal of lung tissue

- Altered oxygen supply (hypoventilation)

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

Possibly evidenced by:

- Dyspnea

- Restlessness/changes in mentation

- Hypoxemia and hypercapnia

- Cyanosis

- Desired Outcomes

Demonstrate improved ventilation and adequate oxygenation of tissues by ABGs within patient’s normal range.

Be free of symptoms of respiratory distress.

Nursing Interventions Rationale

1) Note respiratory rate, depth, and ease of respiration. Observe for use of accessory muscles, pursed-lip breathing, changes in skin or mucous membrane color, pallor, cyanosis. Respirations may be increased as a result of pain or as an initial compensatory mechanism to accommodate for the loss of lung tissue; however, increased work of breathing and cyanosis may indicate increasing oxygen consumption and energy expenditures and/or reduced respiratory reserve.

2) Auscultate lungs for air movement and abnormal breath sounds. Consolidation and lack of air movement on the operative side are normal in the pneumonectomy patient; however, the lobectomy patient should demonstrate normal airflow in remaining lobes.

3) Investigate restlessness and changes in mentation or level of consciousness. May indicate increased hypoxia or complications such as a mediastinal shift in pneumonectomy patient when accompanied by tachypnea, tachycardia, and tracheal deviation.

4) Assess patient response to activity. Encourage rest periods and limit activities to patient tolerance. Increased oxygen consumption demand and stress of surgery can 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. Fever within the first 24 hr after surgery is frequently due to atelectasis. Temperature elevation within the 5th to 10th postoperative day usually indicates a wound or systemic.

6) Maintain patent airway by positioning, suctioning, use of airway adjuncts. Airway obstruction impedes ventilation, impairing gas exchange.

7) Reposition frequently, placing patient in sitting positions and supine to side positions. Maximizes lung expansion and drainage of secretions.

8) Avoid positioning patient with a pneumonectomy on the operative side; instead, favor the “good lung down” position. Research shows that positioning patients 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.

9) Encourage and assist with deep-breathing exercises and pursed-lip breathing as appropriate. Promotes maximal ventilation and oxygenation and reduces or prevents atelectasis.

10) Maintain patency of chest drainage system for lobectomy, segmental or wedge resection patient. Drains fluid from pleural cavity to promote re-expansion of remaining lung segments.

Note changes in amount or type of chest tube drainage. 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 hemothorax; sudden cessation suggests blockage of tube, requiring further evaluation and intervention.

11) Observe presence or degree of bubbling in water-seal chamber. Air leaks immediately postoperative 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 patient versus the drainage system.

12) Administer supplemental oxygen via nasal cannula, partial rebreathing mask, or high-humidity face mask, as indicated. 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.

13) Assist with and encourage the use of incentive spirometer. Prevents or reduces atelectasis and promotes re-expansion of small airways.

14) Monitor and graph ABGs, pulse oximetry readings. Note hemoglobin (Hb) levels. Decreasing Pao2 or increasing Paco2 may indicate the need for ventilatory support. Significant blood loss can result in decreased oxygen-carrying capacity, reducing Pao2.

Deficient Knowledge: Absence or deficiency of cognitive information related to specific topic.

related to

Lack of exposure, unfamiliarity with information/resources
Information misinterpretation
Lack of recall
Possibly evidenced by

Statements of concern; request for information
Inadequate follow-through of instruction
Inappropriate or exaggerated behaviors, e.g., hysterical, hostile, agitated, apathetic.

Desired outcome:

Verbalize understanding of ramifications of diagnosis, prognosis, possible complications.
Participate in the learning process.
Verbalize understanding of therapeutic regimen.
Correctly perform necessary procedures and explain the reasons for the actions.
Initiate necessary lifestyle changes

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5 Lung Cancer Nursing Care Plans

By Matt Vera, BSN, R.N.- Updated on April 10, 20192

Lung cancer is the most common cause of cancer death in men and women. Lung cancer is the carcinoma of the lungs characterized by uncontrolled growth of tissues of the lung. It usually develops within the wall or epithelium of the bronchial tree. Its most common types are epidermoid (squamous cell) carcinoma, small cell (oat cell) carcinoma, adenocarcinoma, and large cell (anaplastic) carcinoma. Although the prognosis is usually poor, it varies with the extent of metastasis at the time of diagnosis and the cell type growth rate. Only about 13% of patients with lung cancer survive 5 years after diagnosis.

Lung cancer is mostly attributable to inhalation of carcinogenic pollutants by a susceptible host. Any smoker older than 40, especially if the person began to smoke before age 15, has smoked a whole pack or more per day for 20 years, or works with or near asbestos. Pollutants in tobacco smoke cause progressive lung cell degeneration. Lung cancer is 10 times more common in smokers than in nonsmokers. Cancer risk is determined by the number of cigarettes smoked daily, the depth of inhalation, how early in life smoking began, and the nicotine content of cigarettes.

Nursing Care Plans

Nursing care for patients with lung cancer revolves around comprehensive supportive care and patient teaching can minimize complications and speed recovery from surgery, radiation and/or chemotherapy.

Here are five (5) lung cancer nursing care plans (NCP) and nursing diagnosis:

Impaired Gas Exchange

Ineffective Airway Clearance

Acute Pain

Fear/Anxiety

Deficient Knowledge

Other Nursing Diagnoses

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5. Deficient Knowledge

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Deficient Knowledge: Absence or deficiency of cognitive information related to specific topic.

May be related to

Lack of exposure, unfamiliarity with information/resources

Information misinterpretation

Lack of recall

Possibly evidenced by:

Statements of concern; request for information

Inadequate follow-through of instruction

Inappropriate or exaggerated behaviors, e.g., hysterical, hostile, agitated, apathetic

Desired Outcomes:

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

Participate in the learning process.

Verbalize understanding of therapeutic regimen.

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

Initiate necessary lifestyle changes.

Nursing Interventions & Rationale:

1) Discuss diagnosis, current and/or planned therapies, and expected outcomes. Provides individually specific information, creating a knowledge base for subsequent learning regarding home management. Radiation or chemotherapy may follow surgical intervention, and information is essential to enable the patient or SO to make informed decisions.

2) Reinforce the surgeon’s explanation of the particular surgical procedure, providing a diagram as appropriate. Incorporate this information into the discussion about short or long-term recovery expectations. Length of rehabilitation and prognosis depend on the type of surgical procedure, preoperative physical condition, and duration or degree of complications.

3) Discuss the necessity of planning for follow-up care before discharge. Follow-up assessment of respiratory status and general health is imperative to assure optimal recovery. Also provides an opportunity to readdress concerns/ questions at a less stressful time.

4) Identify signs and symptoms requiring medical evaluations, e.g., changes in the appearance of incision, development of respiratory difficulty, fever, increased chest pain, changes in the appearance of sputum. Early detection and timely intervention may prevent/ minimize complications.

5) Help the patient determine activity tolerance and set goals. Weakness and fatigue should decrease as lung(s) heals and respiratory function improves during the recovery period, especially if cancer was completely removed. If cancer is advanced, it is emotionally helpful for the patient to be able to set realistic activity goals to achieve optimal independence.