Student Nurses’ Community

NURSING CARE PLAN – Lung Cancer

ASSESSMENT DIAGNOSIS INFERENCE PLANNING INTERVENTION RATIONALE EVALUATION
SUBJECTIVE: Impaired gas Cancer is a After 8 hours of INDEPENDENT: After 8 hours of
exchange class of nursing • Note respiratory rate, • Respiration may be nursing
“Nakakaranas related to diseases intervention the depth, and ease of increased as a intervention the
ako ng hingal sa altered oxygen characterized by patient will respirations. Observe result of pain or as patient was able
paghinga at supply. out-of-control demonstrate for the use of accessory an initial to
panankit ng cell growth, and improved muscles, pursed lip compensatory demonstrate
dibdib” (Lately, I've lung cancer ventilation and breathing, changes in mechanism to improved
been experiencing occurs when adequate skin or mucous accommodate for ventilation and
shortness of breath this uncontrolled oxygenation of adequate
membrane color. loss of lung tissue.
and chest pains) as
cell growth tissues by ABGs Increased work of oxygenation of
verbalized by the begins in one or within patient’s tissues by ABGs
breathing and
patient both lungs. normal range. within patient’s
cyanosis may
Rather than indicate increasing normal range.
developing into oxygen
OBJECTIVE: healthy, normal consumption and
lung tissue, energy
• Restlessnes these abnormal expenditures and
s cells continue reduced respiratory
• Cyanosis dividing and reserve.
• Changes in form lumps or • Auscultate lungs for air • Consolidation and
mentation masses of movement and lack of air
tissue called abnormal breath movement on
• V/S taken as tumors. Tumors sounds. operative side are
follows interfere with normal in the
the main pneumonectomy
T: 37.1 ˚C function of the patient.
P: 101 lung, which is to • Investigate restlessness • May indicate
R: 25 provide the and changes in increased hypoxia
BP: 120/ 80 bloodstream mentation or level of or complications
with oxygen to consciousness. such as mediastinal
be carried to the
shift in
entire body. If a
pneumonectomy
tumor stays in
patient when
one spot and
accompanied by
demonstrates
tachypnea,
limited growth, it
tachycardia, and
is generally
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considered to tracheal deviation.

be benign. More • Maintain patent airway • Airway obstruction
dangerous, or by positioning, impedes ventilation,
malignant, suctioning, use of impairing gas
tumors form airway adjuncts. exchange.
when the cancer
cells migrate to • Reposition frequently, • Maximizes lung
other parts of placing patient in sitting expansion and
the body positions and supine to drainage of
through the side positions. secretions.
blood or lymph
system. When a • Avoid positioning • Positioning the
tumor patient with a patients following
successfully pneumonectomy on the lung surgery with
spreads to other operative side. Favor their “good lung
parts of the the “good lung down” down” maximizes
body and grows, position. oxygenation by
invading and using gravity to
destroying other enhance blood flow
healthy tissues, to the healthy lung,
it is said to have creating the best
metastasized. possible match
This process between ventilation
itself is called and perfusion.
metastasis, and
the result is a
• Encourage or assist • Promotes maximal
more serious
with deep breathing ventilation and
condition that is
exercises and pursed- oxygenation and
very difficult to
lip breathing as reduces or prevent
treat. Lung
appropriate. atelectasis.
cancer is called
"primary" if the
cancer
originates in the
lungs and DEPENDENT:
"secondary" if it • Administer • Maximizes available
originates supplemental oxygen oxygen, especially
elsewhere in the via nasal cannula, while ventilation is
body but has partial rebreathing reduced because
pain.
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metastasized to mask, or high humidity

the lungs. These face mask as indicated. • Decreasing Pao2 or
two types are • Monitor graph of ABGs, increasing PaCO2
considered pulse oximetry may indicate need
different cancers readings. for ventilatory
from diagnostic support.
and treatment
perspectives.