 Karissa  Denise  H.  Gerenia,  BSN  RN    


Lung  cancer  develops  when  genetic  mutations  occur   in  a  normal  cell  within  the  lung.  As  a  result,  the  cell   reproduces  endlessly  and  becomes  a  cancer.   Δ There  are  usually  no  signs  or  early  symptoms  of  lung   cancer.   Δ As   lung   cancer   stages   advance,   lung   cancer   symptoms   may   include   coughing,   wheezing,   shortness  of  breath,  and  bloody  mucus.     Types  of  Lung  Cancer   1. Small  Cell  Lung  Cancer  (SCLC)   a. 20  %  of  all  lung  Ca   b. 99%  association  with  smoking   c. The   most   aggressive   and   rapidly   growing   of   all   lung  Ca   d. Usually  metastatic  at  time  of  diagnosis   e. Paraneoplastic  syndromes  are  common   f. Surgical  resection  not  helpful   2.   Non-­‐Small  Cell  Lung  Cancer  (NSCLC)   a. 80%  of  all  lung  Cancers   b. Surgical  resection  helpful  for  stage  I  and  II   c. Combination  chemotherapy  is  helpful   d. Radiation   used   for   cure   if   disease   is   confined   to   the  chest   e. Categorized  into  three  types   ò Squamous   cell   carcinoma   (also   called   epidermoid   carcinoma),   Adenocarcinoma,   and  Large  cell  carcinoma     Squamous  cell  carcinoma     I. 0%  of  all  lung  Ca   II. Strongly  associated  with  smoking   III. Slower  growing,  less  invasive   IV. Found  in  bronchi  and  peripheral  lung   Adenocarcinoma   I. 30-­‐35%  of  all  lung  Ca   II. Incidence  similar  for  smokers  and  nonsmokers   III. Most  common  lung  Ca  in  women   IV. Metastasis  occurs  early   V. Found  in  peripheral  lung  tissue   Large  cell  carcinomas   I. ≈  10%  of  all  Lung  Ca   II. Sometimes   referred   to   as   undifferentiated   carcinomas   III. Slow  growing   IV. Found  in  peripheral  lung  tissue     **Other   types   of   cancers   can   arise   in   the   lung;   these   types  are  much  less  common  than  NSCLC  and  SCLC  and   together  comprise  only  5-­‐10%  of  lung  cancers:  

ò Bronchial  carcinoids   account   for   up   to   5%   of   lung   cancers.   These   tumors   are   generally   small   (3-­‐4   cm   or   less)   when   diagnosed   and   occur   most   commonly   in   persons   under   40   years   of   age.   Unrelated   to   cigarette   smoking,   carcinoid   tumors   can   metastasize,   and   a   small   proportion   of   these   tumors   secrete   hormone-­‐like   substances.   Carcinoids   generally   grow   and   spread   more   slowly   than  bronchogenic  cancers,  and  many  are  detected   early  enough  to  be  amenable  to  surgical  resection.     ò Cancers   of   supporting   lung   tissue   such   as   smooth   muscle,   blood   vessels,   or   cells   involved   in   the   immune  response  can  rarely  occur  in  the  lung.  


  Table   2   shows   how   the   TNM   staging   information   fits   into  the  number  staging  system.      



Diagnostic  Exams  /  Lab  Tests:   a. Chest   x-­‐ray:   lung   lesions,   cavities   formed   by   squamous  cell  carcinoma,  or  a  lace-­‐like  pattern   of  cells  spreading  through  the  lungs   b. Computed   Tomography   specifically,   low-­‐dose   spiral   (or   helical)   CT   for   determining   if   and   where  the  cancer  has  spread   c. Positron   emission   tomography   (PET)   can   diagnose   lung   tumors   as   small   as   1   centimeter   with   very   high   accuracy.   PET   is   a   good   imaging   technique   for   staging   lung   patients   thought   to   have  early  stage  lung  cancer  after  other  testing.   d. MRI.  Frequently  used  instead  of  CT  scanning  to   locate  brain  and  bone  tumors  that  have  spread   from  the  lung.   e. Thoracoscopy:   diagnosing   cancer   in   the   outer   areas  of  the  lungs,  or  those  involving  the  pleura   f. Bronchoscopy:   locate   cancer   that   develops   in   the  central  areas  and  major  airways  of  the  lung   (usually  squamous  or  small-­‐cell  cancer)   g. Cytologic  examination  of  early  morning  sputum   specimen,  or  fluid  from  pleural  effusion  through   throracentesis.  Biologic  markers  (biomarkers):   i. Enzymes   ii. Hormones   iii. Amino-­‐acid  compounds   iv. Antigens  (identified  by  antibodies  that   specifically  target  them)   v. Growth  factors   vi. Other  chemicals  

PHYSICAL  ASSESSMENT:   Pulmonary   1. Chills,  fever,  and  cough   2. Blood-­‐tinged  /  purulent  and  copious  sputum   3. Hemoptysis  (later  course  of  the  disease)   4. Labored  or  painful  breathing  patterns    -­‐   Use  of  accessory  muscles     -­‐         Flared  nares     -­‐   Stridor     -­‐   Asymmetric  diaphragmatic  movement  on   inspiration   5. Rapid,  shallow  breathing   6. Dyspnea     7. Areas  of  tenderness  or  masses  over  the  chest  wall   8. Increased  chest  fremitus   9. Trachea  may  be  displaced   10. Dull  or  flat  upon  percussion  over  areas  with  masses   11. Breath  sounds  change  with  the  presence  of  tumor:   - Wheezes  (partial  obstruction  of  airflow)   - Decreased  or  absent  breath  sounds  (complete   obstruction)   - Increased  loudness/sound  intensity  of  the  voice   while  listening  to  breath  sounds  (increased   density  of  lung  tissue  from  tumor  compression)   - Pleural  friction  rub  heard  when  inflammation  is   also  present   Nonpulmonary   1. Muffled  heart  sounds  (cardiac  tamponade)   2. Dysrythmias     3. Cyanosis  of  lips  and  fingertips/clubbing   4. Thinning  bones     5. Bone  pain  /  pathologic  fractures   Late  manifestations:   6. Fatigue   7. Weight  loss   8. Anorexia   9. Dysphagia   10. Nausea  and  vomiting   11. Superior  vena  cava  syndrome   12. Lethargy  and  somnolence   13. Confusion  and  personality  changes   14. Diminished  bowel  and  bladder  function   15. Psychosocial:  fear,  anxiety,  guilt  and  shame.     INTERVENTIONS  FOR  CARE   Nonsurgical  Management   1.   Chemotherapy.  It  may  be  used  alone  or  as  adjuvant   therapy  in  combination  w/  surgery  for  NSCLC.  Side   effects   that   occur   with   chemotherapy   for   lung   cancer   include   alopecia,   nausea   and   vomiting,   mucositis,   immunosuppression,   anemia,   and   thrombocytopenia.  (table  3  chemo.agents)  



Table  3  Common  Chemotherapy  Agents  for  Lung  Ca   Generic  Name   Trade  Name   Carboplatin   Paraplatin   Cisplatin   Platinol   Docetaxel   Taxotere   Gemcitabine   Gemzar   Paclitaxel   Taxol   Vinorelbine   Navelbine   *Pemetrexed   Alimta   Nursing  Interventions:     • Reassure   client   that   hair   loss   is   temporary   (make   use   of  wigs,  scarves,  turbans,  and  hats)   • Administer  antiemetic  before  &/  therapy  as  ordered   • Frequent  mouth  assessment  and  oral  hygiene   • Instruct  use  of  soft-­‐bristled  toothbrush  &  avoid  using   dental  floss   • Teach   client   &   family   precautions   to   reduce   client’s   chances  of  developing  infection     2.   Radiation   Therapy.     Best   effective   treatment   for   locally   advanced   lung   cancers   confined   to   the   chest.   Usually   performed   daily   for   a   5-­‐   to   6-­‐week   period.     Side   effects   include   skin   irritation   and   peeling,   fatigue,   nausea,   and   taste   changes.   For   some,  esophagitis  and  narrowing  of  esophagus.       -­‐  External-­‐Beam  Radiation       -­‐  Brachytherapy     Nursing  Interventions:     • Skin   care   on   the   radiation-­‐treated   area:   instruct   client   not   to   wash   off   the   markings   that   outline   the   areas  for  radiation   • Avoid  use  of  lotion/ointments  on  skin  of  chest  unless   radiologists  prescribe  them   • Instruct   client   to   avoid   direct   exposure   to   sunlight   during  treatment  and  at  least  1  year  after  radiation  is   completed     SURGICAL  MANAGEMENT   • The   surgical   removal   of   an   entire   lobe   or   parts   of   a   lung   is   the   primary   treatment   for   eligible   patients   in  the  early  stages  of  cancer   • Recurrence   is   high   after   surgery,   although   the   new   tumor  is  often  operable   • Standard   surgical   procedures   include   Wedge   Resection   or   segmentectomy,   lobectomy,   and   pneumonectomy.   Preoperative   care   goal:   relieve   anxiety   &   promote   client’s  cooperation   • Encourage  client  to  express  fear  and  concerns   • Reinforce  surgeon’s  explanation  of  Sx  procedure   • Provide  education  r/t  what  is  expected  after  Sx  

• Teach  about  the  probable  location  of  incision,  how   to   perform   coughing,   DBE,   shoulder   exercises,   and   about  chest  tube  and  drainage  system   Postoperative  care:   • Maintain   a   patent   airway,   and   monitor   chest   tubes   to  reestablish  normal  intrathoracic  pressure   • Monitor  v/s  and  report  abnormal  respiration   • Suction   patient   often   and   encourage   coughing   and   deep  breathing   • Monitor  chest  drainage;  keep  chest  tubes  patent  and   draining   effectively;   watch   for   air   leaks   and   report   them  immediately   • Position  patient  on  surgical  side  to  promote  drainage   and  lung  expansion   • Adequate  hydration     INTERVENTIONS  FOR  PALLIATION   1.  Supplemental  oxygen  therapy  for  hypoxemic  clients   2.  Drug  therapy:     • Bronchodilators  and  corticosteroids  to  decrease   bronchospasm,  inflammation  &  edema   • Mucolytics   • Appropriate  antibiotic  therapy   3.  Radiation  therapy  to  relieve  hemoptysis,  obstruction   of   bronchi   and   great   veins,   dysphagia,   and   pain   from   bone  metastasis   4.  Laser  therapy  to  debulk  bronchial  obstruction   5.  Dyspnea  management:   • Place  in  semi-­‐fowler’s  position   • Supplemental  oxygen   • Alternate  rest  and  activity  periods   6.  Pain  management:   • Pharmacologic   management   with   opioid   drugs   as   oral   or   parenteral   preparations;   analgesics   round  the  clock   • Nonpharmacologic   measures:   positioning,   hot   or   cold   compresses,   distractions,   and   guided   imagery   • Reduce   or   eliminate   factors   that   precipitate   pain                          



Δ Δ Δ An   infection   of   one   or   both   lungs,   which   is   usually   caused  by  bacteria,  viruses,  or  fungi   Inflammatory   process   leads   to   excess   of   fluid   in   the   lungs   Categorized  as  community-­‐acquired  (CAP)  or   hospital-­‐acquired  (nosocomial)    

  Risk  Factors:   1. Advanced  age   7. 2. Immunocompromised   3. Underlying  lung  disease   8. 4. Alcoholism   9. 5. Altered  consciousness   10. 6. Smoking     Common  etiologic  pathogens:  

Endotracheal   intubation   Malnutrition   Immobilization   Overexposure  to   inclement  weather  

  PATHOPHYSIOLOGY:                                                 DIAGNOSTIC  EXAMS  /  LAB  TESTS:  

1. Gram   stain,   culture   and   sensitivity   testing   of   sputum   2. Complete   blood   count:   leukocytosis   (↑WBC)   more   than  10,000/mm3   Δ Increased  no.  of  neutrophils  –  bacterial  infection   Δ Increased   no.   of   lymphocytes   –   viral,   fungal   and   some  bacterial  infections   3. Blood  culture   Δ To  determine  whether  the  organism  has  invaded   the  blood   4. HIV  test  may  be  performed   Δ Pneumocystis   jiroveci   or   Pneumocystis   carinii   is   causing  the  pneumonia   5. Urinalysis:     Δ Presence  of  blood,  pus,  protein   Δ Streptococcus   pneumoniae   or   Legionella   pneumophila   6. ABG  analysis   Δ Oxygen   level   may   be   decreased   and   carbon   dioxide   level   may   be   normal   or   increased   in   severe  cases  of  Pneumonia   7. Chest  X-­‐ray:       Δ areas  of  increased  density  /  infiltrates   Δ fluid  in  the  chest  cavity  or  a  collapsed  lung   8. Pulse  oximetry   Δ reduced  SaO2  level   9. Transtracheal  aspiration   Δ to  obtain  an  uncontaminated  sputum  specimen   10. Bronchoscopy   Δ to   reveal   any   damage   to   the   lungs   and   also   can   be   used   to   take   a   specimen   from   inside   the   body   for  further  analysis.   11. Direct  needle  aspiration  of  the  lung  /  thoracentesis     COMPLICATIONS   Δ Emphysema  or  pleural  effusion   Δ Endocarditis  or  pericarditis   Δ Pneumococcal  meningitis   Δ Otitis  media  in  children     Δ Abortion   Δ Sepsis   Δ Shock   Δ Respiratory  failure     PHYSICAL  ASSESSMENT   1. General  appearance:  flushed   cheeks,   bright   eyes,   and   an  anxious  expression   2. Non-­‐respiratory  manifestations:   - Fever,   sweating,   headache,   nausea/vomiting   (children),   irritability,   anorexia,   myalgia,   malaise,  fatigue,  tachycardia  



3. Respiratory:   -­‐   Cough     -­‐   Pleuritic  pain  or  discomfort   -­‐   Dyspnea   -­‐   Tachypnea   -­‐   Purulent  sputum  with  bacterial  pneumonia   Scant   sputum   with   viral   pneumonia   and   pneumonia  caused  by  M.  pneumoniae   -­‐   Wheezing:  inflammation  &  exudate  in  airways   -­‐   Signs   of   pulmonary   consolidation:   dullness   to   percussion,   inspiratory   crackles,   increased   tactile   fremitus,   egophony,   and   whispered   pectoriloquy,   chest   expansion   may   be   diminished  or  unequal  on  inspiration     PHARMACOLOGIC  MANAGEMENT   1.  Antibiotics   Δ Penicillins   {amoxicillin,   ampicillin,   clavulanic   acid   (Augmentin,   Augmentin   XR)}   and   cephalosporins   (ceftriaxone,  cefotaxime,  and  cefepime)     Δ Macrolides:   azithromycin,   clarithromycin,   and   erythromycin   Δ Tetracyclines:  doxycycline   Δ Fluoroquinolones:     gemifloxacin,   levofloxacin,   and  moxifloxacin   2.  Supportive  care  for  viral  episodes   o Acyclovir  (Zovirax)  IV  if  origin  is  chickenpox   o Varicella   pneumonia,   which   is   rare,   can   be   treated  with  antiviral  drugs   o Other  antivirals  if  pt  is  immunosuppressed   3.    Mucolytics  to  break  up  secretions   4.    Oxygen  therapy  if  warranted  by  ABG  values  or  pulse   oximetry   Δ Clear  oral,  nasal,  and  tracheal  secretions   Δ Administer  O2  as  ordered   Δ Periodically   check   oxygen   device   to   make   sure   prescribed  concentration  is  delivered     NONPHARMACOLOGIC  MANAGEMENT:   Δ Adequate   hydration   and   good   pulmonary   hygiene:   deep   breathing,   coughing,   chest   physiotherapy     NURSING  DIAGNOSES:   1. Impaired  Gas  Exchange  r/t  effects  of  alveolar-­‐ capillary  membrane  changes   2. Ineffective  Airway  Clearance  r/t  excessive   tracheobronchial  secretions   3. Acute  Pain  r/t  inflammation  of  parietal  pleura   4. Deficient  Fluid  Volume  r/t  increased  metabolic  rate   5. Disturbed  Sleep  Pattern  r/t  persistent  coughing    

NURSING  INTERVENTIONS   1.  Managing  adequate  gas  exchange   Δ Place  pt  in  semi-­‐Fowler’s  position  if  possible   Δ Encourage  pt  to  cough  frequently,  or  suctions  as   necessary   Δ Administer  humidified  O2  as  necessary   Δ Regulate  fluid  intake  to  optimize  fluid  balance   Δ Advise  to  limit  caffeine  intake     2.  Maintaining  patent  airway   Δ Help  pt  to  cough  and  deep  breathe  every  2  hours     Δ Ensure  adequate  hydration  to  thin  secretions   Δ Assist  with  incentive  spirometry  as  appropriate   Δ Instruct  pt  to  avoid  restrictive  clothing  that  could   prevent  adequate  chest  excursion   Δ Administer  bronchodilators  as  necessary     3.  Reducing  Pain   Δ Teach  pt  the  use  of  non-­‐pharmacologic   techniques  to  relieve  chest  pains:  deep  breathing,   guided  imagery,  music,  etc   Δ Position  pt  to  facilitate  comfort   Δ Administer  analgesics  as  ordered     4.  Maintaining  adequate  hydration   Δ Encourage  pt  to  drink  prescribed  fluid  amounts   Δ Provide  oral  hygiene  to  promote  interest  in   drinking   Δ Assist  pt  in  planning  daily  activities  to  control   electrolyte  loss  and  prevent  pt  from  getting  too   tired  at  mealtimes   Δ Administer  parenteral  fluids  as  ordered     5.  Improving  sleep  pattern   Δ Maintain  environment  conducive  to  rest/sleep   Δ Provide  nursing  aids  (back  rub,  pain  relief,   comfortable  position,  relaxation  techniques)  to   promote  rest/sleep   Δ Limit  fluids  before  bedtime  to  reduce  need  for   voiding  during  the  night,  especially  in  elderly    


Δ Persistent,   irreversible   obstruction   of   the   airways   occurring   as   EMPHYSEMA,   CHRONIC   BRONCHITIS,   or  both  

  Chronic  bronchitis:   hypersecretion   of   mucus   and   chronic   productive  cough  for  at  least  3  months  of  the  year  for  at   least  2  consecutive  years    


Emphysema:   abnormal   pertinent   enlargement   of   gas   exchange   airways   accompanied   by   destruction   of   alveolar  walls.     Δ Obstruction  results  from  lung  tissue  changes   rather  than  mucus  production  and   inflammation  as  in  chronic  bronchitis   Δ 2  major  changes:  loss  of  lung  elasticity  and   hyperinflation  of  the  lung  >  result  in  dyspnea   and  the  need  for  increased  RR     PATHOGENESIS  of  Chronic  Bronchitis  &  Emphysema  

ETIOLOGY  AND  GENETIC  RISK   1. Cigarette  Smoking   Δ 8-­‐pack-­‐year  history  usually  has  obstructive  lung   changes  but  no  manifestations  of  dse   Δ 20-­‐pack-­‐years  or  longer  has  early  stage  COPD   2.   Passive  smoking  or  secondhand  smoke   3.   Alpha1-­‐Antitrypsin  Deficiency   Δ AAT:   enzyme   that   prevents   protease   from   damaging  the  lungs   4.   Air  pollution     5.   Age  –  seen  more  in  older  men  

COMPLICATIONS:   1. Hypoxemia  and  Acidosis   ∇ The   lesser   area   for   gas   exchange,   oxygenation   decreases  and  CO2  increases   2.   Respiratory  Infections   ∇ Due  to  increased  mucus  and  poor  oxygenation   ∇ Streptococcus   pneumoniae,   Haemophilus   influenzae,  and  Moraxella  catarrhalis   3.   Cor  Pulmonale   ∇ Right-­‐sided   heart   failure   caused   by   pulmonary   disease  occurs  with  bronchitis  or  emphysema   4.   Cardiac  Dysrhythmias   ∇ Result  of  hypoxemia,  drug  effects,  or  acidosis     DIAGNOSTIC  EXAMS  /  LAB  TESTS     1.   ABG  Analysis   ∇ Abnormal   oxygenation,   ventilation   and   acid-­‐ base  status   2.   Sputum  Analysis   3.   Complete  blood  count   ∇ Increased   WBC   count   helps   confirm   presence   of   infection   ∇ Hemoglobin   ∇ Hematocrit   4.   Serum  ATT  levels  for  suspected  ATT  deficiency   5.   Chest  X-­‐ray   ∇ Rule  out  other  chest  diseases   ∇ Advanced  emphysema:  hyperinflation  and   flattened  diaphragm   6.   Pulmonary  Function  Test   ∇ Vital  Capacity   ∇ Residual  volume  –  mostly  affected  (↑)   ∇ Total  lung  capacity   ∇ Forced  Expiratory  volume   ∇ Forced  Vital  Capacity  (the  ratio  of  FEV  to  FVC  is   smaller  as  COPD  progresses)   ∇ Diffusion  Test  measures  how  well  a  test  gas   (carbon  monoxide)  diffuses  the  aveolo-­‐capillary   membrane  and  combines  with  the  hemoglobin   of  the  RBCs.    In  emphysema:  decreased   diffusion  capacity.  Bronchitis:  diffusion  capacity   is  usually  normal   ∇ Pulse  oximetry  –  decreased  O2  saturation     NONSURGICAL  MANAGEMENT   1.  Airway  Maintenance   ∇ Keep   the   pt’s   head,   neck,   and   chest   in   alignment     ∇ Assist   him/her   to   liquefy   secretions   and   clear   the  airway  of  secretions  



2.  Monitoring   ∇ Assess  the  hospitalized  pt  every  2  hours   ∇ Provide  the  prescribed  oxygen,  assess  response   to  treatment  and  prevent  complications   ∇ If  condition  worsens,  intubation  and  mechanical   ventilation  may  be  needed   3.  Oxygen  Therapy   ∇ Relief  of  hypoxemia  and  hypoxia   ∇ 2-­‐4L/min  via  nasal  cannula  or  up  to  40%  via   Venturi  mask   4.  Drug  Therapy   ∇ Beta-­‐adrenergic  agents      Albuterol  (Ventolin)  inhalation      Bitolterol  (Tornalate)   ∇ Cholinergic  antagonists        Iptratropium  (Atrovent)  inhalation   ∇ Methylxanthines      Theophylline  (Theo-­‐Dur,  Uniphyl)      Aminophylline  (Truphylline)   ∇ Corticosteroids      Prednisolone  (Delta-­‐Cortef)  oral      Prednisone  (Deltasone,  Prednicot,  Orasone)      Budesonide  (Pulmicort)  inhalation      Fluticasone  (Flovent)  metered-­‐dose   ∇ Cromolyn  sodium  (mast  cell  stabilizers)   ∇ mucolytics          Acetylcysteine  (mucomyst)     SURGICAL  MANAGEMENT   1.   Lung  transplantation  is  performed  for  select  clients   with  end-­‐stage  COPD   2.   Lung  reduction  surgery  –  the  goal  is  improvement   of  gas  exchange  through  removal  of  hyperinflated   lung  tissue.   § After  successful  surgery,  most  clients  have  at   least  75%  improvement  in  FEV  and  increased   activity  tolerance.  Oxygen  therapy  may  no   longer  be  needed     Preoperative  care:   § Patient  must  complete  pulmonary  rehabilitation   before  surgery  to  maximize  lung  &  muscle   function.   § Patient  must  be  able  to  walk  without  stopping   for  30  minutes  at  1  mile/hour   § Maintain  a  90%  or  better  O2  saturation   Postoperative  Care:   § Close  monitoring  for  continuing  respiratory   problems  as  well  as  postop  complications   § Usual  post-­‐thoracotomy  care   § Bronchodilator  and  mucolytic  therapies  are   maintained  initially  

§ § §

Incentive  spirometry  10  times  per  hour  while   awake   Chest  physiotherapy  starting  on  the  1st  day  after   surgery  and  hourly  pulmonary  assessment   Pain  is  managed  by  epidural  delivery  of  opioids   during  early  period  after  surgery  


  NURSING  INTERVENTIONS   1.  Airway  Management   a. Position  pt  to  maximize  ventilation  potential   b. Perform  chest  physiotherapy  as  appropriate   c. Remove  secretions  by  encouraging  coughing  or   by  suctioning   d. Instruct  how  to  cough  effectively   e. Assist  with  incentive  spirometer,  as  approp.   f. Administer  bronchodilators,  as  appropriate.   g. Teach  client  how  to  use  prescribed  inhalers   h. Administer  humidified  O2  as  appropriate   i. Regulate  fluid  intake  to  optimize  fluid  balance   2-­‐3  L/day   j. Regularly  monitor  respiratory  and  oxygenation   status     2.  Cough  Enhancement     a. Assist  pt  to  a  sitting  position  with  head  slightly   flexed,  shoulders  relaxed,  and  knees  flexed   b. Encourage  pt  to  take  several  deep  breaths   c. Encourage  pt  to  take  a  deep  breath,  hold  it  for  2   seconds,  and  cough  2  or  3  times  in  succession   d. Instruct  pt  to  inhale  deeply  several  times,  to   exhale  slowly,  and  to  cough  at  the  end  of   exhalation   3.  Oxygen  therapy   a. Clear  oral,  nasal  and  tracheal  secretions   b. Maintain  airway  patency   c. Set  up  O2  equip  and  administer  through   humidified  system   d. Monitor  O2  liter  flow     4.  Energy  Management   a. Determine  pt’s  physical  limitations   b. Ensure  adequate  nutritional  intake   c. Limit  environmental  stimuli   d. Arrange  alternate  rest  and  activity  periods   e. Assist  pt  to  identify  tasks  that  family  and  friends   can  perform  at  home  to  prevent  fatigue            

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