University of the Philippines Manila

The Health Sciences Center

COLLEGE OF NURSING
WHO Collaborating Centre for Leadership in Nursing Development
Commission on Higher Education (CHED Center for Excellence)
Sotejo Hall, Pedro Gil St., Ermita, Manila
Tel.: (632)523-1472 / Telefax: (632)523-1485

A Case Study

on

Lung Adenocarcinoma

In partial fulfillment on the requirements

In MAN- Adult Health Nursing
Philippine General Hospital
1st Semester- 2019-2020

Presented by:

Francis Anthony B. Losloso, RN

Presented to:

Lydia T. Manahan, PhD, RN

Alyssa Jenny Tupaz, RN, MN

1
Table of Contents
I. Chapter I
a. Introduction 3
b. Rationale 4
c. Objectives 4
d. Nursing Health History 5
i. Demographic Data 5
ii. Chief Complain 5
iii. History of Present Illness 6
iv. Past Medical History 6
v. Family History Genogram 7
vi. Gordon’s Functional Health Pattern 8
vii. Risk and Predisposing factors and cause of illness 11
II. Chapter II
a. Review of Related Literature 12
b. Conceptual framework/ pathophysiology of the case 16
III. Chapter III
a. Methodology 18
b. Review of systems 18
c. Physical Examination 19
d. Diagnostic and Laboratory Results 27
e. Plan of Care 31
f. Priority Nursing Problems 32
g. Health Instructions 37
IV. Chapter IV
a. Pathophysiology of the patient 39
V. Chapter V
a. Evaluation of Care 40
b. Learning Experiences 40
c. Conclusion/ Recommendation 40
VI. References 42

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 Chapter 1
I. Introduction:
Lung cancer is the leading cause of cancer-related death worldwide.
Approximately 2.1 million diagnoses are estimated in 2018, contributing about 11.6%
of the total cancer incidence burden according to World Health Organization (WHO,
2018). It is also responsible for the largest number of deaths (1.8 million deaths, 18.4%
of the total) because of the poor prognosis for this cancer worldwide. It is commonly
diagnosed in men wherein 14.5% of the total cases are attributed to them and 8.4%
in women. According to Brunner and Suddarths’, the incidence of lung cancer in men
remained relatively constant, but in women it continues to rise. According to the latest
global cancer data of the World Health Organization, in 2018, lung cancer is the
leading cause of death in women in 28 countries. Highest incidence rates are seen in
North America, Northern and Western Europe, China and may be associated to
climate related smoking. In the Philippines, there are 17, 255 (12.2%) new cases of
lung cancer in both sexes and 5,069 (6.4%) of which are females and has a mortality
rate of 17.9% among all cancer related deaths.

One of the major risk factors of lung cancer is tobacco smoking. This means that
not only men engage or are exposed in cigarette smoking, but as well as women. In
an article of quit.org there are 3 common reasons why people smoke; 1. nicotine
addiction, 2. situational triggers such as smoking with relatives, friends or during
occasions and 3. emotional triggers when stressed, bored or upset. On the other hand,
even non-smokers may be diagnosed with lung cancer and is commonly associated
with lung adenocarcinoma. Lung adenocarcinoma is a subtype of non-small cell lung
cancer which is commonly diagnosed in people who have never smoked. It starts in
glandular cells which secretes substances such as mucus, and tends to develop in
smaller airways, such as alveoli. It usually occurs in the lung periphery, and in many
cases, may be found in scars or areas of chronic inflammation.

The patient is a 53-year old female who is known to have lung adenocarcinoma.
She was admitted in the cancer institute for her scheduled chemotherapy.

3
 II. Rationale for choosing the study
The student had 3 reasons why he chose this study. First, his father is a chronic
smoker, he smokes about 10-20 sticks per day for the past 30 years and definitely
believed that the student is at risk since he has been exposed to second hand
smoke since childhood. Second is that the student became interested in his
patient’s case and became curious about having diagnosed with lung cancer
despite the fact that she does not smoke, has no vices and had been a victim of
second hand smoke. And third, he wanted to explore and learn more about the
disease process of lung cancer and how to manage it starting from health
promotion, disease prevention, disease management and until death.

III. Objectives:
General objective:
To apply the theories and best practices learned in nursing oncology in
planning, implementing and evaluating nursing intervention in patient with lung
cancer.

Patient-Centered Objectives:
At the end of the clinical immersion, the patient will be able to:
1. Establish rapport with the nurse
2. Verbalize feelings and concerns regarding present condition
3. Identify existing and potential problems that may occur in and out of the hospital
4. Develop a care plan together with the nurse
5. Demonstrate appropriate independent interventions in managing symptoms
6. Commit to planned interventions
7.
Nurse-Centered Objectives:
At the end of the clinical immersion, the nurse will be able to:
1. Identify risk factors associated with lung adenocarcinoma
2. Understand the pathophysiologic process of lung adenocarcinoma
3. Correlate significant health history and findings with patient’s diagnostic results.

4
4. Integrate appropriate nursing and medical management based on patient’s
significant findings
5. Evaluate effectiveness of care rendered to the patient

IV. Nursing Health History

A. Demographic Data

Name: RVP
Sex: F
Age: 53 years old
Birthday: 1966
Address: Batangas City
Race: Filipino
Religion: Roman Catholic
Marital Status: Married
Admission Date: October 18, 2019
Education: High school graduate
Occupation: Previous employment
Barangay Nutritionist 2008-2009
Barangay Health Worker 2009-2011
Small-town lottery collector 2011-2018
Blood type: O positive

B. Chief Complaint:
7th cycle of chemotherapy

Admitting Medical Diagnosis:

Lung Adenocarcinoma

5
 C. History of Present Illness:
October 2018:
1-year prior to admission- Patient experienced difficulty of breathing associated with
persistent cough and weight loss. She sought consult at a local traditional healer
(albularyo) and eventually went to a nearby hospital at Batangas. Routine blood exam
and chest imaging was done but was not able to follow-up the results. One of her family
members suggested to seek consult at Philippine General Hospital due to financial
constraints. Despite persistent difficulty of breathing and 3-pillow orthopnea, no further
medical consultation done nor medications taken.

January 2019:
9 months prior to admission- Decided to sought consult due to worsening difficulty of
breathing and weight loss associated with weakness, back pain and chest pains
characterized as stabbing pain with unrecalled pain scale, patient decided to go to
Philippine General Hospital and seen as an out-patient. She experienced 3-pillow
orthopnea and easy fatiguability. She was assessed having pleural effusion and 1.4 Liters
of clear fluid was aspirated from her left lung field in the minor operating room of the out-
patient clinic and she showed signs of symptom relief. Biopsy was also done revealing
lung adenocarcinoma. Chemotherapy was recommended as medical management and
since then she was regularly admitted once a month for chemotherapy. She started last
April 2019 to July 2019 in which she received Paclitaxel and Carboplatin and on August
2019 she was given unrecalled chemotherapeutic agent until present (October 2019).

D. Past Medical History:

Patient has been healthy since childhood and had very active lifestyle. She completed
her immunization during childhood and has no known allergies to food and medication.
She has not been involved to any accidents and did not have any recent foreign travel.
She has no vices; she is not a smoker nor an alcoholic drinker. She denied use of illicit
drugs as well. She has a husband who is a chronic smoker, her father was also a smoker
and may assume that she had been exposed since childhood. She was not diagnosed of
any communicable (tuberculosis) and non-communicable (hypertension, diabetes,

6
 cancer, stroke, cardiovascular) diseases in the past until such time she was diagnosed
with lung adenocarcinoma. She had first menstruation when she was 14 years old and
had regular menstrual period that last for 3-5 days. She experienced occasional
dysmenorrhea and consumes 2-3 moderately soaked pads per day. She had 5 healthy
full-termed living children and did not experienced any miscarriages nor abortion. She
was a barangay health nutritionist and worker for 3 years and had good health seeking
behavior but since she became a small-town lottery collector for 7 years, it may be
considered that she has been exposed to smoke and other environmental factors from
roaming around different barangays. She has been hospitalized every month since April,
2019 for chemotherapy and did not undergo any surgical interventions.

E. Family History

x
Asthma bronchopneumonia

rvp

Smoker 3 packs/day

28 25 23 22 19

Male

3
Female
9
3y Patient
9o
There are no significant health related findings from her grand-parents. y
o

7
 F. Gordon’s Functional Health Patterns:

Functional Before Hospitalization During Hospitalization

Health Pattern
Health She had no history of being sick during her She is more equipped with
Perception/ childhood days. She is not a smoker nor an knowledge regarding the disease
Health alcoholic and denied use of illegal drugs. She process and portrays positive
Management thought that she had been living a healthy life not attitude and acceptance to it. She
knowing that she has been at risk from getting committed to continuously
lung cancer from the start. She had been undergo regular follow-ups and
following doctor’s orders and recommendations chemotherapy treatment and
since she was a barangay health worker and compliance to dietary and
knows the consequences when not followed. She medication regimen. She is able to
religiously follows treatment and chemotherapy name current medications and its
procedures as scheduled. purpose with good compliance.
Nutritional- She had been eating healthy foods and most of it She had electrolyte imbalance of
Metabolic are prepared at home. She seldom eats at fast hypokalemia and
food restaurants. By the time she experienced hypomagnesemia. Her weight
weakness and weight loss due to disease upon admission was 29 kg. She
process, she had poor appetite and as time goes committed in following the
by, she already lost 23 kilograms, from 52kg to appropriate dietary regimen to
29kg on admission. Even though she tried to prevent malnutrition and
increase her food intake, she cannot meet her electrolyte imbalance. She
dietary daily requirements. ensures and verbalized that she
will try her best to keep up with her
nutritional needs.
Elimination She verbalized good urinary output and did not She verbalized that she has good
experience any urinary distention, incontinence urinary output however, upon
nor dysuria. She also had regular bowel reviewing her records, it showed
movements in the morning. that throughout her 5 days
admission she has been retaining

8
 water as evidenced by her intake
and output as shown in the
assessment findings. These
findings may put the patient at risk
for fluid volume excess. She
eventually mentioned that she will
record her intake and output even
at home.
Activity- She can provide self-care needs such as eating, Despite her easy fatiguability and
Exercise hygiene care and minimal activities such as weakness, she mentioned that
walking however she easily gets tired. She no she will still continue to walk in the
longer does heavy chores such as laundry due to morning and do basic chores such
occasional weakness and the risk of experiencing as dishwashing as a form of her
difficulty of breathing. Her son that lives with her daily exercise.
is the one doing the chores.
Cognitive- She is a high-school graduate and possesses She is conscious, coherent and
Perceptual basic knowledge in health care since she has oriented to three spheres. She has
been involved in a health center. She verbalized good attention span and
that she has good decision-making skills cooperative during interview.
however, her chronic illness may affect her
mental and sensory function since there is a risk
for her disease to metastasize in the brain. She
experienced localized chest pains due to left lung
tumor that is characterized as stabbing with pain
scale of 5-7/ 10.
Sleep-Rest She verbalizes trouble sleeping and experienced She sleeps with 1-2 pillows due to
3-pillow orthopnea and occasionally wakes up at unavailability of an extra pillow but
night due to difficulty of breathing. does not complain or verbalize
orthopnea. She plans to continue
sleeping at home with 3- pillows to
avoid breathing problems.

9
Self- The patient is over-all comfortable with her She is comfortable with her
Perception/ appearance and verbalized that she has no shy appearance. She did not show
Self-Concept about her baldness. She just wears a bonnet any feelings of discomfort towards
comfortably to cover her head. She does not her current appearance. She
show any feelings of discomfort towards her verbalized confidence in wearing
current appearance and shows acceptance of a bonnet to cover her head but she
her chronic illness. seemed to be hesitant about her
statement. However, she still
insisted that it is alright about it
and is aware that it is a normal
side-effect of her chemotherapy.
Role- She has a good relationship with her family. She She continues to have good
Relationship lives with her husband and her 5 children. She relationship with her family and
verbalized some disappointment in her husband spend a lot of time with them.
due to his smoking habits that had caused her
being diagnosed with lung cancer but they still
have good relationship.
Sexuality- She did not show any interest in sexuality. She did not show any interest in
Reproductive sexuality.
Coping/ She uses her mobile device to play games as a She commits to explore other
Stress form of stress reliever. She did not have any other forms of coping mechanism such
Tolerance form of stress reliever however she shows as doing activities she like that
positive attitude towards her chronic illness. does not require a lot of energy.
She verbalized good support
system since she is with her
family.
Value-Belief She goes to local faith/ traditional healers when She values her belief spiritually
she experiences sickness. She is a roman and verbalized her understanding
catholic and expressed her belief by praying. and importance of going to more
knowledgeable, qualified and

10
 professional doctors and health
care providers.

G. Risk and Predisposing factors and cause of Illness

Generally, major causes of lung cancer are aging, genetics, exposures in radon
gas, asbestos, smog, radiation, primary and secondary smoking, presence of
respiratory diseases and occupation. However, patient RVP were not exposed to
certain physical nor chemical carcinogens except secondhand smoking. She was
never a smoker and has been associated with her diagnosis of having lung
adenocarcinoma.

11
 Chapter II
I. Review of Related Literature
Lung Cancer
Lung cancer is defined by lungcancer.org (2019) as the uncontrolled
growth of abnormal cells in one or both lungs. These abnormal cells do not carry
out the function of normal lung cells and do not develop into healthy lung tissue.
Lung cancers are grouped into two main types called small cell and non-small
cell lung cancer. Small cell lung cancer is characterized as small, round oval cells
that are approximately the size of lymphocytes and develops centrally. It grows
fast and there is rapid metastasis are likely to occur since it is highly malignant
and tends to infiltrate widely and disseminate early in their course. On the other
hand, Non-small cell lung cancer is more common than small cell lung cancer
and is divided into three subtypes. Adenocarcinoma is a glandular structure that
which generates mucin. It is common in women and non-smokers and originates
from the bronchial or alveolar tissues. Squamous cell carcinoma is associated
with smoking and is more common in men. It produces keratin and develops
centrally and may be detected earlier through cytologic exam of sputum. Large
cell carcinoma lacks both glandular and squamous differentiation and both
develop centrally and peripherally which is highly anaplastic and difficult to
categorize as adenocarcinoma or squamous cell carcinoma. Different types of
lung cancer grow differently and are treated differently.

Global incidence of lung cancer

According to the World Health Organization, lung cancer is the leading
cause of cancer-related deaths worldwide. Approximately 2.1 million diagnoses
are estimated in 2018, contributing about 11.6% of the total cancer incidence
burden according to World Health Organization (WHO, 2018). It is also
responsible for the largest number of deaths (1.8 million deaths, 18.4% of the
total) because of the poor prognosis for this cancer worldwide.

12
Local incidence of lung cancer
In the Philippines, there are 17, 255 (12.2%) new cases of lung cancer in
both sexes and 5,069 (6.4%) of which are females and has a mortality rate of
17.9% among all cancer related deaths.

Lung adenocarcinoma
Lung adenocarcinoma is a cancer that occurs due to abnormal and
uncontrolled cell growth in lungs. It is a subtype of non-small cell lung cancer that
is often diagnosed in an outer area of the lung. It is common in women and non-
smokers and originates from the bronchial or alveolar tissues. It starts in
glandular cells which secretes substances such as mucus, and tends to develop
in smaller airways, such as alveoli. It usually occurs in the lung periphery, and in
many cases, may be found in scars or areas of chronic inflammation.

Lung cancer in female

It is commonly diagnosed in men wherein 14.5% of the total cases are
attributed to them and 8.4% in women. According to Brunner and Suddarths’, the
incidence of lung cancer in men remained relatively constant, but in women it
continues to rise.

According to the latest global cancer data of the World Health

Organization, in 2018, lung cancer is the leading cause of death in women in 28
countries. Highest incidence rates are seen in North America, Northern and
Western Europe, China and may be associated to climate related smoking.
Incidence of lung adenocarcinoma in females may be associated to second hand
smoking since it is common to those who are non-smokers.

Etiology of lung cancer

Major cause of lung cancer is tobacco use, particularly cigarette smoking.
In an article of quit.org there are 3 common reasons why people smoke; 1.
nicotine addiction, 2. situational triggers such as smoking with relatives, friends

13
or during occasions and 3. emotional triggers when stressed, bored or upset.
Lung cancer cells may have >10 acquired genetic lesions, most common
mutations in ras oncogenes; amplification, rearrangement, or transcript activation
of myc family oncogene; overexpression of bcl-2, Her-2/neu and telomerase; and
deletions involving chromosomes 1p, 1q, 3p12-13, 3p14, 3p21, 3p24-25, 3q, 5q,
9o, 11p13, 11p15, 13q14, 16q and 17p13 (p53 gene). Loss of 3p and 9p are the
earliest events, detectable even in hyperplastic bronchial epithelium; p53
abnormalities and ras points mutations are usually found only in invasive cancers
(Harrison’s Manual of Medicine, 16th ed.). Other causes of lung cancer are
occupational and environmental exposures to radon gas, asbestos, air pollution,
ionizing radiation such as x-ray and secondhand smoking. Even non-smokers
may be diagnosed with lung cancer and is commonly associated with lung
adenocarcinoma.

Clinical manifestations of lung cancer

Only 5-15% are detected while asymptomatic. Central endobronchial
tumors cause cough, hemoptysis, wheeze, stridor, dyspnea, pneumonitis.
Peripheral lesions cause pain, cough, dyspnea, symptoms of lung abscess
resulting from cavitation. Metastatic spread of primary lung cancer may cause
tracheal obstruction, dysphagia, hoarseness, Horner’s syndrome (Harrison’s
Manual of Medicine, 16th ed.). Superior vena cava syndrome may occur to
patients with mediastinal involvement in which there is an interruption of blood
flow in the superior vena cava resulting from compression by the tumor or
involved lymph nodes. Pleural effusion may also arise due to involvement of
visceral pleura that compress lungs and may lead to atelectasis.

Diagnostics and work-ups in lung cancer

Careful history taking and physical examination is important in diagnosing
lung cancer. It may be confirmed through chest x-ray wherein tumor/s may be
located and search for pulmonary density, solitary peripheral nodule, atelectasis
and infection. Computed tomography scan to determine metastasis in the brain,

14
bone scan for bone metastasis, liver ultrasound for liver involvement, fiberoptic
bronchoscopy may also be done for detailed study of the tracheobronchial tree,
bronchoscopy, positron emission test scan to identify metastatic lesions in the
mediastinum or distant sites, cytologic studies and biopsy for confirm histologic
findings.

Management of Lung adenocarcinoma

Management of lung adenocarcinoma is to provide cure if possible. It may
involve surgery, radiation therapy and chemotherapy or combination of these.
Palliative care may also be provided to patients in a form of radiation therapy to
shrink tumor to provide pain relief, a variety of bronchoscopic interventions to
open a narrowed bronchus or airway and pain management and other comfort
measures. Symptomatic management may also be done to prevent dyspnea
such as oxygen supplementation, feeding tubes for those patients who have
trouble eating per orem or has poor to loss of appetite and infection prevention
and control.

15
 II. Conceptual Framework/ Pathophysiology of the lung adenocarcinoma

Aging, Genetics, Smoking, Second hand

smoking, Exposure to occupational
carcinogen (radon, asbestos, radiation,
pollution), Respiratory diseases

Chromosomal deletion Activation of oncogenes Activation of telomerase

Inactivation of tumor Epithelial growth factor

suppressor genes (TSG) receptor is upregulated Telomere lengthening enzyme

TSG loss (p53 mutation) Binding of EGF Protects ends of chromosomes

activates signaling from unraveling
cascades that
cell progression modulates the
transcription of Prolonged cell survival
genes important in
cell proliferation
DNA damage unchecked
and resistance to
apoptosis

Faulty cells proceed

through cell cycle

Impaired regulation of Apoptosis is evaded

apoptosis
vegF binds to vegF receptors

Cells susceptible to mutation

Formation of new blood
vessels
Tumor cells promote angiogenesis

Sustain tumor growth

Production of vascular
endothelial growth factor

16
 Pathogenesis of lung adenocarcinoma started from carcinogen-induced initiation
events followed by long period of promotion and progression in a multistep process.
Exposure to cigarette such as secondhand smoke both initiates and promotes
carcinogenesis. The initiation happens early on, as evidenced by similar genetic
mutations (e.g. 3p deletion, p53 mutation). It causes a field effect on the lung
epithelium, providing a large population of initiated cells and increasing the chance of
transformation. Continued smoke exposure allows additional mutations to accumulate
due to promotion by chronic irritation and promoters in cigarette smoke (e.g. nicotine,
phenol, formaldehyde). The time delay between smoking onset and cancer onset is
typically long, requiring 20-25 years for cancer formation. Cancer risk decreases after
smoking cessation, but existing initiated cells may progress if another carcinogen
carries out the process. NSCLC often has mutations in EGFR, KRAS, CD44 and p16.
These are either tumor suppressor genes or oncogenes.

In summary, risk factors such as aging, genetics and occupational carcinogens

may lead to chromosomal deletion, activation of oncogenes and activation of
telomerase which may result to evasion of apoptosis and angiogenesis that may
sustain tumor formation and growth.

17
 Chapter III
I. Methodology
The students were given 4 days of clinical exposure in the cancer institute ward.
On the first day of clinical exposure, endorsement of ward patients was done and each
student were given the chance to choose 3 patients among the 39 endorsed patients.
The student decided to take care of patients diagnosed with lung adenocarcinoma,
nasopharyngeal carcinoma and acute myeloid leukemia. Rationale of choosing such
patients were based on the following: nasopharyngeal carcinoma since the student is
a nurse at the department of otorhinolaryngology, lung adenocarcinoma and acute
myeloid leukemia since he became interested with the disease process. Series of data
gathering were done through interview from primary source of information which is the
patient and the secondary source which is the caregiver and the chart. On the second
and third day of clinical exposure, continuous data gathering and evaluation of the
current interventions was done. Problems were identified by the nurse together with
the patient and started to plan for health improvement. On the last day of clinical
exposure, group health teaching based on the identified health needs was conducted
in patients currently admitted in the cancer institute. After the clinical exposure, the
student took interest in the patient’s case diagnosed with lung adenocarcinoma as his
case study to further explore the disease process.

II. Review of Systems:

Skin: Dry skin, no visible lesions, scars, tattoos.

Head: (+) alopecia, no headaches or head injury.
Eyes: No blurring of vision, pain, glaucoma, cataracts, jaundice.
Ears: No hearing loss, tinnitus, ear discharge.
Nose: No bleeding, stuffiness and colds.
Allergies: No known allergies, swelling, asthma and hives.
Mouth: No sore throat, sore tongue, hoarseness and bleeding gums, with moist
mucosa.
Neck: No lumps, swollen glands, goiter, stiffness.

18
 Breast: No lumps, pain, nipple discharge
Respiratory: 3-pillow orthopnea, no productive cough, sputum, hemoptysis
Cardiac: no hypertension, cardiac medications, no angina but with (+) occasional
stabbing pain at left chest, tumor related with pain scale of 5-7/10
Gastrointestinal: (+) weight loss, (+) loss of appetite, no change in bowel habits
Urinary: No anuria, dysuria, no abnormal vaginal discharges
Peripheral vascular: No leg cramps, varicose veins, thrombophlebitis, bleeding
Musculoskeletal: No fracture, amputation
Neurologic: No headache, seizures, loss of consciousness, fainting, confusion,
paralysis, involuntary movements, incoordination, numbness and tingling
sensation
Hematologic: Anemic, no bleeding, hematoma, bruises
Endocrine: Decrease in appetite, no signs of thirst, heat/cold intolerance,
excessive sweating, diabetes

Analysis:
Patient experienced 3-pillow orthopnea due to presence of pulmonary mass that
compromises her breathing. It was associated with loss of appetite that lead to anemia
and weight loss leading to multiple electrolyte imbalance (hypokalemia,
hypomagnesemia), malnutrition and may put the patient at risk for infection. It may also
be caused by chemotherapy.

III. Physical Examination:

VITAL SIGNS:
Temperature: 36-37.2*C
Heart Rate: 78-88bpm
Respiratory Rate: 17-22cpm
Blood Pressure: 100/90-120/70
Oxygen Saturation: 96-98%
Pain Scale: 5-7/10 left chest pain characterized as stabbing pain

19
ANTHROPOMETRIC MEASUREMENTS:
Height: 150 cm
Weight: 29 kg
Previous weight (before diagnosis): 52kg
Ideal body weight: 43.5kg
Body Mass Index: 12.88 (underweight)
Arm hole: 31cm
Waistline: 27in
Hip: 29in
Waist: Hip Ratio: 0.93
Thigh: 18cm

GENERAL SURVEY:
• Conscious, coherent, oriented to three spheres
• With support to some activities of daily living that requires more effort (standing
from bed to floor, going to comfort rooms, walking up and down the stairs)
• Does not exhibit any signs of cardiorespiratory distress
• Looks, behaves and acts consistently with age and sex
• Generally light brownish skin; dry skin
• No foul body smell; has medication-related alopecia and well-trimmed nails
• Able to relax and maintain eye contact
• Soft -voice, has moderate pace of speech
• Thin
• Alopecia

NEUROLOGIC STATUS:
• Oriented to three spheres: person, place, time
• No aphasia, agnosia, apraxia
• Intact recent, immediate and remote memory
• Good judgement, insight and abstract thinking
• No hallucinations and delusions

20
 • Cranial Nerve I: Able to identify smell of food
• Cranial Nerve II: 3mm, equally and briskly reactive to light and accommodation
• Cranial Nerve III, IV, VI: No ptosis or lid lag, with good extraocular movements on
both eyes
• Cranial Nerve V: Brisk, bilateral corneal reflex, has good masseter tone and
strength
• Cranial Nerve VII: No facial palsy; intact taste sensation
• Cranial Nerve VIII: Intact gross hearing on both ears
• Cranial Nerve IX, X, XI: With good gag reflex and shoulder shrug
• Cranial Nerve XII: Tongue in midline,
• Sensory: 100% on both upper and lower extremities
• Motor: 5/5 on both upper and lower extremities
• Meningeal: No signs of Brudzinski and Kernig

SKIN:
• Normal light brownish color, no jaundice, cyanosis and pallor
• Dry skin
• Warm to touch
• Good skin turgor
• Capillary refill <2 seconds

HEAD AND FACE:

• Normocephalic and symmetrical; no palpable mass; no scars
• Medication associated hair loss, presence of alopecia
• The scalp is clean with no masses, lesions and scars
• No bruit on temporal artery, absence of tenderness
• CN V: Symmetrical and equal muscle on both sides
• CN VII: Symmetrical facial expression, movements and strength

21
EYES:
• Able to read cellphone texts with 12 font size with 1 armlength distance
• No blindness or blurring of vision
• CN II: 3mm, equally and briskly reactive to light and accommodation
• Cranial Nerve III, IV, VI: No ptosis or lid lag, with good extraocular movements on
both eyes
• Cranial Nerve V: Brisk, bilateral corneal reflex
• Pinkish palpebral and bulbar conjunctiva
• Anicteric sclera
• Eyebrows symmetrically aligned and have equal movement hair evenly distributed
and skin intact
• Eyelashes equally distributed and curled slightly outwards
• Eyelids symmetrical and in level with each other with bilateral blinking
• No discharge, swelling or lesions
• No tearing of the lacrimal duct upon palpation

EARS:
• No foul-smelling ear discharge with minimal dry cerumen
• Normoset and bilaterally symmetrical; same color with face
• No visible lumps or lesion; proportionate with head and face
• No tenderness or pain felt
• Pinkish and patent ear canal; intact tympanic membrane
• Symmetrical gross hearing
• CN VIII: Able to hear whisper about 1 feet distance, able to hear ticking of watch,
sound lateralizes to both ears equally

NOSE:
• Symmetrical nasolabial fold; no deformities, lesions, deviations
• Septum in midline, pinkish mucosa
• No masses, polyps, discharges

22
 • Both patent
• CN I: Intact sense of smell; able to distinguish familiar odors (alcohol, fruits)
• No nasal or alar flaring, no tenderness in sinuses

MOUTH:
• Pinkish dry lips
• Intact speech, no slurring and drooling
• Lips can close symmetrically; no lumps, cracks and ulcers
• CN XII: Tongue in midline, no atrophy, fasciculations and lesions
• Buccal mucosa is pink, moist and has no lesions or ulcerations
• Pinkish gums

PHARYNX:
• Uvula in midline with pinkish mucosa
• Bilateral symmetrical rise of soft palate and uvula
• No tonsillar inflammation and exudates
• CN IX and X: With good gag reflex; symmetrical contraction of trapezius muscles

NECK:
• No enlargement or tenderness of parotid gland
• Trachea in midline, no neck vein engorgement
• Non-tender, non-palpable lymph nodes
• Non-palpable thyroid
• No visible masses, neck enlargement, lesions
• Carotid artery with symmetrical rate and rhythm
• CN XI: Full range of motion and symmetrical muscle strength and movement of
the neck
• Good shrug

23
CHEST AND LUNGS:
• Respiratory rate: 17-22 cpm
• Regular rhythm
• With occasional use of accessory muscles while doing activities that require efforts
(standing at bedside, going up and down the stairs)
• With decreased left upper and lower lung sound
• Unequal chest expansion
• Decreased tactile fremitus on left side
• Inspiration/ expiration ratio 1:1
• No intercostal space retractions
• No bulging
• Apicolordotic ratio 1:2
• 3- pillow Orthopnea
• (+) Chest pain, characterized as stabbing pain tumor-related, 5-7/10 pain scale

HEART:
• Normal precordium
• Heart rate at 5th intercostal space, left midclavicular line (PMI)
• Regular rhythm
• No heaves and thrills
• No murmurs
• No pericardial friction rub
• Distinct heart sounds with S1 louder than S2 at apex and S2 louder than S1 at
base

BREAST AND AXILLAE:

• Unequal and unsymmetrical breasts, (+) bilateral loss of breast mass, (+) bilateral
wrinkled breast skin
• No dimpling and masses, no engorgement
• No nipple retraction, discharge and tenderness

24
 • No palpable mass, no tenderness and no lymphadenopathy in axilla

ABDOMEN:
• Soft, flat abdomen
• No visible enlargement of spleen and liver
• No pulsations, protrusions on umbilicus
• Tympanitic upon percussion
• No direct tenderness, rebound tenderness and muscle guarding upon palpation
• No bladder distention
• No fluid wave and shifting dullness

GENITO-URINARY:
• No vaginal discharges, nodules, growth or lesions
• No Dysuria
• Intake and Output for 5 days
Date Input Output
10/18 2200 1450
10/19 2650 1150
10/20 4200 1500
10/21 3170 1100
10/22 2450 2400

BACK AND EXTREMITIES:

• With intravenous cannula gauze 24 at left metacarpal vein to 0.9 sodium chloride
1 liter + 2.5grams magnesium sulfate + 20meqs potassium chloride to run for 8
hours x 2 cycles 1/2
• Pink nailbeds
• Sensory: 100% on both upper and lower extremities
• Motor: 5/5 on both upper and lower extremities
• Strong, equal radial, popliteal, dorsalis pedis pulses

25
 • Good capillary refill: <2 seconds
• No CVA tenderness, fractures
• Able to pick-up or grasp small objects with good strength

Analysis:
The patient had significant assessment findings in the chest area since she has
lung adenocarcinoma. Pulmonary mass further compresses patient nearby tissues
eliciting pain on the left lung fields with a pain scale of 5-7/10 and was managed with pain
medications. This compression may also put the patient at risk for superior vena cava
syndrome if not managed. This pulmonary mass also affects patient’s ventilation which
presents as decreased left upper and lower lung lobe associated with decreased tactile
fremitus and unequal chest expansion. Patient also presents occasional use of accessory
muscles while doing activities that requires efforts leading to easy fatiguability and may
be associated with tachypnea up to 22cpm. 3- pillow orthopnea was also assessed to
relieve patient’s difficulty of breathing. Adjacent tissues such as the breast tissues were
assessed and there is an unequal and unsymmetrical breast mass and wrinkled skin.
Further weight loss may be linked to patient’s cachexic condition may be due to weakness
or chemotherapy that may lead to malnutrition as evidenced by weight loss (29kg), BMI
of 12.88 characterized as underweight and multiple electrolyte imbalance in which the
nurse received the patient with intravenous therapy of 0.9 sodium chloride + 2.5 grams
magnesium sulfate + 20 meqs potassium chloride to run for 8 hours x 2 cycles, ½. It has
been assessed that patient may be at risk for fluid volume excess as seen her fluid input
and output wherein input and output difference ranging from 50ml to maximum of 2700ml
has been noted. It is important to continuously assess fluid input and output as well as
breath sounds and extremities to prevent congestion leading to difficulty of breathing.

26
 IV. Diagnostics and Laboratory Results:

Blood Normal 10/21/19 10/18/19 Interpretation

Chemistry levels
Potassium 3.6-5.1 2.9 3.4 Low levels of Potassium in the blood may cause
mmol/L cardiac arrhythmias and neurologic disturbances,
intravenous and oral potassium (refer to drug study)
were given to increase serum potassium levels of the
patient. ECG should be readily available to rule out
presence prominent u waves and potential life-
threatening arrhythmias. Low potassium levels may
also be associated with her nutritional status not
having adequate intake of food rich in potassium. Also,
the patient has fluid retention which may cause dilution
potassium levels in the blood. It is also associated with
chemotherapy indirectly via side effects of decreased
appetite/ intake, vomiting and diarrhea or directly via
renal tubular effects. Hypokalemia treatment is
ineffective if hypomagnesemia remains uncorrected,
due to unchecked potassium losses via the renal outer
medullary K+ channel in distal nephron tubular cells
(Shirali, 2016).
Magnesium 0.70-1.00 0.64 0.58 Low levels of magnesium in the blood, may be due to
mmol/L poor intake of magnesium rich foods. Intravenous
magnesium administration has been given to the
patient which increased serum magnesium from 0.58
to 0.64. Hypomagnesemia in cancer patient may be
also be associated from renal magnesium wasting. It
is principally due to chemotherapy-mediated injury to
the distal nephron, the site of active magnesium
reabsorption in the nephron. Chemotherapeutic agents

27
 that target the epidermal growth factor receptor
pathway may be attributable to this effect. In cases with
platin drugs, renal magnesium wasting may be
permanent. It is necessary to assess renal function in
this matter (Shirali, 2016).
Creatinine 46-92 45 Creatinine result does not show significant deviation
umol/L from normal range. It is an end-product of protein
metabolism and used to assess glomerular filtration.
Kidney function needs to be assessed to monitor
kidney function since some chemotherapeutic drugs
are nephrotoxic. Relating it to patient’s hypokalemic
and hypomagnesemia state, it important to assess
renal function to assess presence of injury to distal
nephrons caused by chemotherapeutic drugs.
AST 14-36 U/L 20 Normal level, no liver damage. Liver function needs to
be assessed to rule out liver metastasis. It is also
important to identify presence of deterioration of
hepatic function because it may increase the risk of
other systemic side effects because drug metabolism
is influenced by liver dysfunction. Hepatotoxicity
following chemotherapy mostly attributes to either
applied drugs or potential confounding disease. One of
the patient’s chemotherapeutic drug is Paclitaxel in
which it is one of the chemotherapeutic drugs that has
been approved for first-line treatment of Non-small cell
lung cancer (NSCLC), of which pemetrexed displays
superior effectiveness and has become the
preferential drug of lung adenocarcinomas.
ALT <35 IU/L 15 Within acceptable level, no liver damage. Liver
function needs to be assessed to rule out liver
metastasis.

28
CBC Normal levels 10/21/19 10/18/19 Interpretation
WBC 4.5-11.0x10^9/L 15.00 9.00 High levels of WBC suggest presence of infection.
Immune system is compromised due to chemotherapy
and may also be increased due to the presence of
tumor. Tumor-related leukocytosis may also be
considered which is caused mainly by the unregulated
production of hematopoietic cytokines.
RBC 4.2-5.4x10^12/L 3.62 3.03 Red blood cells carry oxygen throughout the body.
Having low levels of RBC may indicate anemia and
may also decrease oxygen carrying capacity. 1 unit of
packed red blood cells were transfused to increase red
cells. Low RBC may also explain why the patient
experietnce easy fatiguability. Chemotherapy may
lower red blood cells count.
Hgb 120-160 g/L 109 95 Hemoglobin is the amount of protein in red blood cells
that carries oxygen. Low levels of hemoglobin may be
an indication of iron-deficiency anemia. Poor oxygen
transport due to low oxygen carrying red cells. 1 unit of
packed red blood cells were transfused to increase
oxygen carrying red cells in the body.
Hct 0.38-0.47 0.33 0.28 Hematocrit is the percentage of blood that is made up
of red blood cells. Low levels of hematocrit may be an
indication of iron-deficiency anemia.
MCV 80-96 fL 91.8 93.3 Normal levels of MCV indicates that the cells have
there is a normal volume of red blood cells.
MCH 27-31 pg 30.1 31.4 Normal levels of MCH indicates normal amount of
hemoglobin in an average cell.
MCHC 320-360 g/L 328 336 Normal level indicates average concentration of
hemoglobin per erythrocyte.
RDW 11.0-16.0 15.1 14.8 Normal level indicates uniformity of individual cell size.

29
PC 150-450x10^9/L 240 294 Normal levels of Platelet. Less likely to have bleeding
tendencies. Clotting abilities are still functioning well.
Neutrophil 0.50-0.70 0.77 0.65 Neutrophils are the dominant leukocytes in the blood.
It is the first line of defense against inflammation and
infection. High levels suggest inflammation. It
dominates the immune cell composition in NSCLC.
Tumor reactive lymphocyte T cells are also frequently
present.
Lymphocyte 0.20-0.50 0.12 0.20 Low levels of lymphocytes may have decreased
defense from viral infections.
Monocyte 0.02-0.09 0.07 0.11 High levels of monocytes suggest that there are active
phagocytic cells that remove foreign materials or
microorganism from site of injury (tumor).
Eosinophil 0-0.06 0.04 0.03 Normal level indicates absence of allergic reaction.
Basophil 0-0.02 0.00 0.01 Normal level indicates absence of allergic reaction.
Absolute Neutrophil Count:
ANC= WBC x total neutrophils (segmented neutrophils % + segmented bands%) x 10

=15 x 0.77 x 10 ANC = 115.5, low ANC, patient is at high risk of developing
infection.
Histopathology:
1/23/19
Lung Mass, Left, Computed Tomography- Guided Aspiration Biopsy
Nonsmall cell carcinoma, favor adenocarcinoma
2/22/19
Lung Mass, Left, Computed Tomography- Guided Aspiration Biopsy
CK7: Positive, strong and diffuse cytoplasmic staining and neoplastic cells.
TTF1: Positive, strong and diffuse nuclear staining in neoplastic cells.
CK20: Negative no staining observed in neoplastic cells
Immunohistomorphologic features are consistent with an adenocarcinoma from a lung
primary.

30
IV. Plan of Care

Short term Plan:

1. Establish rapport with the patient to ensure that the patient will be able to
participate and involve with the assessment, planning, implementation and
evaluation of care.
2. Let the patient identify existing and potential problems that may occur in and out
of the hospital to broaden patients’ knowledge and perspective regarding the
disease process.
3. Develop a care plan that will prevent the patient from experiencing difficulty of
breathing, increase appetite to prevent malnutrition and weight and interventions
to prevent infection.
4. Able to make the patient demonstrate appropriate and independent intervention
that may manage her symptoms.
5. Have the patient commit to her plan of care.

Long term Plan:

1. To prevent or slow the progression of her chronic illness so that she can maximize
her time spent with her family.
2. To prevent potential health problems that may occur by following the treatment
regimen and dietary instructions given by the health care team.
3. To comply with the necessary schedule of chemotherapy to prevent further
complication and progression of the disease.
4. To have a positive outlook and attitude in life so that she will be motivated in her
daily life.
5. To strengthen her relationship with her family so that she will be able to have good
support system that may be beneficial specially in terms of coping.

31
 V. Priority Nursing Problems
Patient RVP
NURSING CARE PLAN

Cues Nursing Diagnosis Background Goals and Objectives Nursing Interventions & Rationale Evaluation
Knowledge
S- “Alam ko na mga Domain 11 Class 1 Code Patient diagnosed At the end of the 4 Risk for infection At the end of the
gagawin ko, maliban sa 00004 with lung day exposure, the NIC: Oral Health Promotion (1720) 4 day exposure,
sinabi mo, ano-ano pa Risk for infection related adenocarcinoma patient will be able to: -monitored condition of patient’s mouth the patient was
ba kailangan ko to malnutrition and presented with 1. Maintain -provided oral health assessment able to:
malaman?” inadequate secondary multiple nursing temperature within -determined patient’s usual dental hygiene routine 1. Maintain
“Kakain na ako ng mga defenses and problem that the normal range -instructed patient and caregiver on frequency and quality of temperature
magugulay at pagkaing immunosuppression as requires (36.4-37.4*C) proper oral health care within the normal
mayaman sa vitamins at evidenced by WBC: 15 management. 2. Prevent developing range (36.4-
electrolytes” Neutrophils 0.77 Primarily, it is due signs and symptoms of NIC: Cough Enhancement (3250) 37.4*C)
“Parati ako maghuhugas to presence of infection -encouraged to take several deep breaths, deep breath then 2. Prevent
ng kamay” Domain 3 Class 4 Code pulmonary mass 3. Maintain WBC and held it for 2 seconds and cough 2-3x in succession developing signs
“Magpapalakas ako 00030 and may also be differential count and symptoms of
para magawa ko yung Impaired gas exchange associated with within acceptable NIC: Medication (2380) infection
mga dapat ko pang related to presence of treatment such as levels -determined what drugs are needed and administered 3. Maintain WBC
gawin” as verbalized by pulmonary mass as chemotherapy. 4. Maintain clear according to prescriptive authority and differential
the patient evidenced by dyspnea, Poor appetite breath sounds -discussed financial concerns related to medication regimen count within
decreased breath resulted to 5. Demonstrate -monitored for effectiveness of medication acceptable levels
O-Vital Signs: sounds, orthopnea malnutrition and comfortable body -determine patients’ ability to self-medicate as appropriate 4. Maintain clear
HR 78-88bpm cachexia in which positions -monitored patient for therapeutic effect breath sounds
RR- 18-20cpm Domain 4 Class 3 Code patient has risk of 6. Demonstrate deep -monitored signs and symptoms of drug toxicity 5. Demonstrate
BP 100/90-120/70 00093 developing breathing exercises -monitored adverse effect of drug comfortable body
T 36-37.2*C Fatigue related to infection, fatigue 7. Verbalize -monitored non-therapeutic drug interactions positions
O2sats 94-98% malnutrition as due to lack of importance of having -determined patients knowledge about medication 6. Demonstrate
Pain 5-7/10 at left lower evidenced by unable to caloric intake, adequate sleep during -financial resources for acquisition of prescribe drug deep breathing
chest near the chest accomplish task that imbalanced nights (Philhealth, DOH, local government) exercises
wall requires effort such as nutrition that 8. Verbalize -determined impact of medication use on patients lifestyle 7. Verbalize
Weight loss from 52kg transferring from bed to lead to appropriate activities -instructed patient to seek medical attention as needed importance of
-weight upon chair independently, electrolyte to consume energy having adequate
admission: 29kg climbing 1 flight of stairs imbalances and during the day such as NIC: Nutrition Management (1100) sleep during
Alopecia possible fluid walking as a form of -determined patient’s nutritional status and ability to meet nights
Dyspnea Domain 2 Class 1 Code retention. exercise, basic chores nutritional needs 8. Verbalize
00002 Imbalanced Dyspnea, that does not require -identified patient’s food allergies or tolerance appropriate

32
3-pillow orthopnea- nutrition: Less than body decreased breath too much effort such -determined patient’s food preferences activities to
relieved by 3 pillows requirement related sounds and as washing dishes -instructed patient about nutritional need (foods rich in consume energy
Persistent non- insufficient dietary orthopnea is also 9. Plan and choose magnesium and potassium, foods high in calories for energy) during the day by
productive cough intake associated with present due to appropriate dietary -encouraged family/caregiver to bring patient’s favorite trying to walk for
Decreased breath cancer as evidenced by lung involvement. regimen enumerating foods while in hospital or care facility as appropriate atleast 3-5
sounds on left upper inadequate food intake, food rich in -instructed patient on diet requirements for disease state minutes every
and lower lung lobe weight of 29kg from electrolytes -monitored dietary intake morning and
Decreased tactile 52kg, waist hip ratio: 10. Commit to -instructed caregiver to monitor trends in weight loss and accomplishing
fremitus on left lung 0.93, electrolyte increase food intake gain task that does not
lobe imbalance of K-2.9 and to increase current require too much
Decreased appetite Mg-0.64 body weight Additional intervention for infection management effort as a form of
(+) intravenous fluid 11. Normalize levels of -Ensure good hand, oral and body hygiene mobilization and
access Domain 2 Class 5 Code serum potassium and -Encourage hand washing exercise
Input and output for 5 00195 magnesium -Perform procedures aseptically 9. Plan and
days Risk for electrolyte 12. Prevent from -Monitor temperature choose
10/18 I: 2200 O: 1450 imbalance related to experiencing pain -Monitor CBC with differential WBC and obtain blood appropriate
10/19 I: 2650 O: 1150 excess fluid volume as cultures if indicated dietary regimen
10/20 I: 4200 O: 1500 evidenced by K-2.9, Mg Overall goal is to: enumerating food
10/21 I: 3170 O: 1100 0.64 1. Infection prevention Fatigue rich in
10/22 I: 2450 O: 2400 2. Normalize NIC: Sleep enhancement (1850) electrolytes such
Domain 2 Class 5 Code electrolyte levels (K, -explained importance of adequate sleep during illness as green leafy
Dx: 00026 Mg) -encouraged patient to establish a bedtime routine to vegetables,
WBC: 15 high Excess fluid volume 3. Promote good facilitate transition from wakefulness to sleep bananas and
Neutrophils: 0.77 high related to fluid shifting nutrition taking vitamin as
Lymphocyte: 0.12 as evidenced increased 4. Promote good Additional intervention for fatigue management supplements
Eosinophil: 0.9 fluid intake and breathing exercises -Encouraged patient to perform ADLs and participate in 10. Commit to
RBC: 3.62 low decreased fluid output, desired activities increase food
Hgb: 109 low tachypnea, decreased -Schedule activities wherein patient has the most energy and intake to increase
Hct: 0.33 breath sounds on left schedule resting periods current body
Creatinine: 45 lung lobes -Involve caregivers in providing self-care needs/ assistance weight and caloric
Mg: 0.64 intake to increase
K: 2.9 Domain 1 Class 2 Code Fluid volume excess energy
00162 Readiness for NIC: Electrolyte management: hypokalemia (2007); 11. normalize
enhanced health hypomagnesemia (2008) levels of serum
management as -monitored trends in magnesium and potassium levels as potassium and
evidenced by desire to available magnesium (K-
enhance choices of daily -monitored imbalances associated with hypomagnesemia 3.7mmol/L, Mg-
living for meeting goals, (hypokalemia) 0.7mmol/L)

33
expresses desire to -monitored for reduced intake due to malnutrition 12. Pain scale
enhance management -instructed intake of food rich in magnesium (unmiled grains, decreased to 5/10
of illness, prescribed green leafy vegetabes, nuts and legumes), food rich in after
regimens, risk factors potassium (dried fruits, bananas, green vegetables, administration of
and symptoms tomatoes, dairy products) pain medication
-received with ongoing IV magnesium replacement as
Domain 6 Class 1 Code ordered
00185 Readiness for -monitored for CNS, neuromuscular, GI, cardiovascular
enhanced hope as manifestation of hypomagnesemia
evidenced by desire to -received oral potassium replacement as ordered
enhance ability to set -monitored cardiac, renal, neurological manifestations of
achievable goals hypokalemia
-monitored for fluid status

NIC: Positioning (0840)

-positioned moderate-high back rest or sitting position to
alleviate dyspnea

Imbalanced nutrition: less than body requirement

Nutritional management
-Encouraged to monitor food intake and have food diary
available
-Encouraged patient to eat high calorie, nutrient-rich diet
with adequate food intake.
-Involved relatives in creating and sharing foods with patient
-Referred to dietitian for computation of dietary needs

NIC: Vital signs Monitoring (6680)

-monitored heart rate, respiratory rate, blood pressure,
temperature, oxygen saturation, lung and heart sounds, color
-monitored v/s before and after meals

Interventions not based on NIC:

1. Monitored vital signs (HR, BP, RR, O2 sats, T)
2. Monitored intake and output accordingly
3. Assessed for breathing pattern and breath sounds,
monitoring signs of congestion

34
 4. Facilitated deep breathing exercises and coughing
technique
5. Positioned the patient in an upright/ 3-pillow to
relieve dyspnea
6. Administered pain medication (Tramadol +
Paracetamol 37.2/325 mg/ tab TID as needed for
pain). Assessed pain levels and characteristics of
pain, 5/10 stabbing pain at left chest
7. Assessed for signs and symptoms of altered level of
consciousness, bone pain, abdominal pain
8. Administered fluids (0.9 sodium chloride 1liter) +
electrolytes (potassium chloride 20meqs +
magnesium sulfate 2.5grams) IV as ordered
9. Administration of oral potassium chloride 10%
solution 30 cc and was shifted to tablets as ordered
10. Started pre-chemotherapy medications as ordered
(ondansetron 8 mg IV and dexamethasone 20mg IV)
as ordered
11. Started chemotherapy protocol, flushing of 500ml
dextrose 5% in water x 30 minutes, administration
of Carboplatin 600mg then Etoposide
12. Facilitated health teachings of infection prevention
and control and hand hygiene
13. Facilitated health teachings of appropriate dietary
selection
14. Facilitated identification of activities to be done by
the patient at home
15. Encouraged son to assist patient in daily activities

Prioritization of Care Plan:

1. Risk for Infection needs to be prioritized knowing that the patient has increased WBC, it means that it is active white
blood cells are currently fighting pathogens or infections. Infection may lead to further complication that may risk patients
present condition. Patient RVP is currently undergoing chemotherapy and may affect destruction of WBC that may put her
at immunocompromised state and may be vulnerable to microorganisms. Fever, cough, colds and complete blood count
must be monitored and prevention of infection must be done such as good hand hygiene, isolation and continuous
monitoring must be done.

35
2. Excess fluid volume is next to be prioritized knowing that patient had experienced pleural effusion in the past, it is likely
to occur and may lead to difficulty of breathing. Strict fluid intake and output must be monitored together with the breath
sounds and other respiratory parameters.
3. Risk for electrolyte imbalance is the rank third since patient experiences loss of appetite, inadequate food intake rich in
electrolytes are likely to occur. This may lead to several problems such as fatal dysrhythmias.

36
VI. Health Instructions

Medication:
Current medications that patient RVP is taking in-hospital. No final list of
medications has been stated as take-home medications.

Medication Dose and Frequency Time

Tramadol + Paracetamol 37.5/325mg/tab 1tab 3x/day as needed for As needed
pain

Exercise:
Encouraged patient to have active mobilization when she is not experiencing any
weakness, light exercise such as walking to promote good circulation. Shoulder rotations
and leg stretches even at bed are encouraged to promote flexibility and mobilization.

Treatment
Follow monthly scheduled chemotherapy in cancer institute to receive maximum
effect of treatment.

Home Environment
Ensure that there are means of support at home such as bar handles on comfort
room or stair handles to prevent fall in case patient experienced weakness. Emphasis
was given on lowered bed but maintained patient on moderate high back rest position to
promote good breathing. Discussed means of preventing acquisition of infection at home
by encouraging good hand-washing, good and smoke-free ventilation.

OPD follow-ups
There is no follow-up schedule yet but encouraged patient to seek consultation
religiously and as needed when another problem arises.

37
Diet
Discussed dietary regimen with patient. Encouraged to eat adequately based on
dietitian’s recommendation and caloric requirement to prevent further weight loss and
malnutrition. Foods rich in electrolytes such as potassium and magnesium such as
bananas and green leafy vegetables were given emphasis since patient experienced
electrolyte imbalance. Patient was able to commit in continuing appropriate dietary
regimen tailored to her current chronic illness.

Spirituality
Encouraged to pray regularly as a form of worship and relaxation.

38
 IV. Chapter IV
I. Pathophysiology of the Patient

39
 V. Chapter V
I. Evaluation of Care
The goal for this patient was met since the overall goal is to ensure that the
patient will be able to engage herself in planning and executing interventions related to
her chronic illness. She was able to understand the importance of infection prevention
and control, prevention of malnutrition by taking adequate and appropriate selection of
foods, prevention of complications such as difficulty of breathing and division of tasks
throughout the day for time management that may also improve her sleep by utilizing
her energy in the morning in forms of light exercises and light activities. The patient
was able to verbalize understanding and committed with the plan of care together with
her son as her primary caregiver.

II. Learning Experiences

As an ENT nurse, my knowledge is limited from head down to the neck area in
terms of oncology nursing. I have learned several things from this case study since I
was able to explore the organ responsible for our respiration. Few main points are the
disease process of lung adenocarcinoma. I also learned different types of lung cancer
and most importantly that even living a healthy lifestyle, one can be diagnosed with
cancer. It is important for us to ensure and live the teachings of Florence Nightingale
regarding her environmental model and to continue educate and actively campaign to
stop smoking.

III. Conclusion and Recommendation

Chronic illness such as being diagnosed with cancer is very difficult to deal with
knowing that despite living a healthy lifestyle, one may be at risk in developing lung
cancer through occupational and environmental factors such as second hand smoking.
No wonder that lung cancer is one of the leading causes of cancer related deaths
because it is often referred as the “silent killer” due to its characteristic of being
asymptomatic in the first few stages. Early detection through regular check-ups or
annual physical assessment with chest imaging may be recommended for early
recognition of the disease. Active health promotion and disease prevention must be

40
practiced with the support of the different programs of the government such as anti-
smoking campaigns may help entire community to be aware and understand the
consequences of smoking and second hand smoke. Strong and unyielding support
system must be given to establish a positive outlook from the patient towards the
chronicity of her illness.

41
VI. References:
Primary source: Patient
Secondary source: Patient chart, son
Brunner, L. S., Suddarth, D. S., Smeltzer, S. C. O., & Bare, B. G. (2004). Brunner &
Suddarth's textbook of medical-surgical nursing (10th ed.). Philadelphia: Lippincott
Williams & Wilkins.
Shirali MD, A., Electrolye and Acid-Base Disorders in Malignancy (2016). Section of
Nephrology, Yale University School of Medicine, New Haven, Connecticut
https://www.who.int/cancer/PRGlobocanFinal.pdf
https://gco.iarc.fr/today/data/factsheets/populations/608-philippines-fact-sheets.pdf
https://www.ncbi.nlm.nih.gov/books/NBK519578/
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5950590/
https://www.youtube.com/watch?v=J5UfBV18Bis
https://www.lungcancer.org/find_information/publications
https://onlinelibrary.wiley.com/doi/full/10.1002/1097-
0142(20011101)92:9%3C2399::AID-CNCR1588%3E3.0.CO;2-W
https://www.elitecme.com/resource-center/laboratory/interpreting-the-complete-blood-
count-and-differential/
Kee, J. L., Hayes, E. R., & McCuistion, L. E. (2006) Pharmacology: A Nursing Process
Approach (5th ed.). Singapore: Elsevier.
Medscape (2019). Medscape WebMD LLC. [Mobile application software]. Retrieved from
http://play.google.com/store
MIMS Philippines (2018). MIMS Drug Refence: Concise Prescribing Information (155 th
ed.). Singapore

42
43