Student Nurses Community

NURSING CARE PLAN Lung Cancer

ASSESSMENT
SUBJECTIVE:
Nakakaranas
ako ng hingal sa
paghinga at
panankit ng
dibdib (Lately, I've
been experiencing
shortness of breath
and chest pains) as

verbalized by the
patient
OBJECTIVE:
Restlessness
Cyanosis
Changes in
mentation
V/S taken as
follows
T: 37.1 C
P: 101
R: 25
BP: 120/ 80

DIAGNOSIS

INFERENCE

PLANNING

INTERVENTION

Impaired gas
exchange
related to
altered oxygen
supply.

Cancer is a
class of
diseases
characterized by
out-of-control
cell growth, and
lung cancer
occurs when
this uncontrolled
cell growth
begins in one or
both lungs.
Rather than
developing into
healthy, normal
lung tissue,
these abnormal
cells continue
dividing and
form lumps or
masses of
tissue called
tumors. Tumors
interfere with
the main
function of the
lung, which is to
provide the
bloodstream
with oxygen to
be carried to the
entire body. If a
tumor stays in
one spot and
demonstrates
limited growth, it
is generally

After 8 hours of
nursing
intervention the
patient will
demonstrate
improved
ventilation and
adequate
oxygenation of
tissues by ABGs
within patients
normal range.

INDEPENDENT:
Note respiratory rate,
depth, and ease of
respirations. Observe
for the use of accessory
muscles, pursed lip
breathing, changes in
skin or mucous
membrane color.

RATIONALE

Auscultate lungs for air

movement and
abnormal breath
sounds.

Investigate restlessness
and changes in
mentation or level of
consciousness.

Respiration may be
increased as a
result of pain or as
an initial
compensatory
mechanism to
accommodate for
loss of lung tissue.
Increased work of
breathing and
cyanosis may
indicate increasing
oxygen
consumption and
energy
expenditures and
reduced respiratory
reserve.
Consolidation and
lack of air
movement on
operative side are
normal in the
pneumonectomy
patient.
May indicate
increased hypoxia
or complications
such as mediastinal
shift in
pneumonectomy
patient when
accompanied by
tachypnea,
tachycardia, and

EVALUATION
After 8 hours of
nursing
intervention the
patient was able
to
demonstrate
improved
ventilation and
adequate
oxygenation of
tissues by ABGs
within patients
normal range.

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considered to
be benign. More
dangerous, or
malignant,
tumors form
when the cancer
cells migrate to
other parts of
the body
through the
blood or lymph
system. When a
tumor
successfully
spreads to other
parts of the
body and grows,
invading and
destroying other
healthy tissues,
it is said to have
metastasized.
This process
itself is called
metastasis, and
the result is a
more serious
condition that is
very difficult to
treat. Lung
cancer is called
"primary" if the
cancer
originates in the
lungs and
"secondary" if it
originates
elsewhere in the
body but has

tracheal deviation.
Airway obstruction
impedes ventilation,
impairing gas
exchange.

Maintain patent airway

by positioning,
suctioning, use of
airway adjuncts.

Reposition frequently,
placing patient in sitting
positions and supine to
side positions.

Maximizes lung
expansion and
drainage of
secretions.

Avoid positioning
patient with a
pneumonectomy on the
operative side. Favor
the good lung down
position.

Positioning the
patients following
lung surgery with
their good lung
down maximizes
oxygenation by
using gravity to
enhance blood flow
to the healthy lung,
creating the best
possible match
between ventilation
and perfusion.

Encourage or assist
with deep breathing
exercises and pursedlip breathing as
appropriate.

Promotes maximal
ventilation and
oxygenation and
reduces or prevent
atelectasis.

Maximizes available
oxygen, especially
while ventilation is
reduced because
pain.

DEPENDENT:
Administer
supplemental oxygen
via nasal cannula,
partial rebreathing
mask, or high humidity

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metastasized to
the lungs. These
two types are
considered
different cancers
from diagnostic
and treatment
perspectives.

face mask as indicated.

Monitor graph of ABGs,
pulse oximetry
readings.

Decreasing Pao2 or
increasing PaCO2
may indicate need
for ventilatory
support.