ASSESSMENT NURSING INFERENCE OBJECTIVES NURSING RATIONALE EVALUATION

DIAGNOSIS INTERVENTION
INDEPENDENT:
Subjective: Impaired gas Cancer is a class After 8 hours of  Note respiratory rate,  Respiration may be After 8 hours of
exchange related of diseases nursing depth, and ease of increased as a result of nursing intervention
“Nakakaranas ako
to altered characterized by intervention the respirations. Observe pain or as an initial the patient was able
ng hingal sa
oxygen supply. out-of-control patient will for the use of compensatory to demonstrate
paghinga at
cell growth, and demonstrate accessory muscles, mechanism to improved ventilation
panankit ng
lung cancer improved pursed lip breathing, accommodate for loss of and adequate
dibdib” (Lately,
occurs when this ventilation and changes in skin or lung tissue. Increased oxygenation of
I've been
uncontrolled cell adequate mucous membrane work of breathing and tissues by ABGs
experiencing
growth begins in oxygenation of color. cyanosis may indicate within patient’s
shortness of breath
one or both tissues by ABGs increasing oxygen normal range.
and chest pains) as
lungs. Rather within patient’s consumption and energy
verbalized by the
than developing normal range. expenditures and
patient
into healthy, reduced respiratory
Objective: normal lung reserve.
tissue, these
 Restlessness abnormal cells  Auscultate lungs for  Consolidation and lack
 Cyanosis continue air movement and of air movement on
 Changes in dividing and abnormal breath operative side are
mentation form lumps or sounds. normal in the
masses of tissue pneumonectomy patient.
 V/S taken as called tumors.
follows Tumors interfere  Investigate  May indicate increased
with the main restlessness and hypoxia or
T: 37.1 ˚C function of the changes in mentation complications such as
P: 101 lung, which is to or level of mediastinal shift in
R: 25 provide the consciousness. pneumonectomy patient
BP: 120/ 80 bloodstream when accompanied by
with oxygen to tachypnea, tachycardia,
be carried to the and tracheal deviation.
entire body. If a
tumor stays in  Maintain patent  Airway obstruction
one spot and airway by impedes ventilation,
demonstrates positioning, impairing gas exchange.
limited growth, suctioning, use of
it is generally airway adjuncts.
considered to be
benign. More  Reposition  Maximizes lung
dangerous, or frequently, placing expansion and drainage
malignant, patient in sitting of secretions.
tumors form positions and supine
when the cancer to side positions.
cells migrate to
other parts of  Avoid positioning  Positioning the patients
the body patient with a following lung surgery
through the pneumonectomy on with their “good lung
blood or lymph the operative side. down” maximizes
system. When a Favor the “good lung oxygenation by using
tumor down” position. gravity to enhance blood
successfully flow to the healthy lung,
spreads to other creating the best
parts of the body possible match between
and grows, ventilation and
invading and perfusion.
destroying other
healthy tissues,  Encourage or assist  Promotes maximal
it is said to have with deep breathing ventilation and
metastasized. exercises and pursed- oxygenation and reduces
This process lip breathing as or prevent atelectasis.
itself is called appropriate.
metastasis, and
the result is a
more serious
condition that is DEPENDENT:
very difficult to  Administer  Maximizes available
treat. Lung supplemental oxygen oxygen, especially while
cancer is called via nasal cannula, ventilation is reduced
"primary" if the partial rebreathing because pain.
cancer mask, or high
originates in the humidity face mask
lungs and as indicated.
"secondary" if it
originates  Monitor graph of  Decreasing Pao2 or
elsewhere in the ABGs, pulse increasing PaCO2 may
body but has oximetry readings. indicate need for
metastasized to ventilatory support.
the lungs. These
two types are
considered
different cancers
from diagnostic
and treatment
perspectives.
 ASSESSMENT NURSING INFERENCE OBJECTIVES NURSING RATIONALE EVALUATION
DIAGNOSIS INTERVENTION
INDEPENDENT
Subjective: Acute pain Lung cancer i After 8 hours of -Provide comfort -Promotes relaxation and After 8 hours of
related to tissue s the most nursing measures such as redirects attention. Relieves nursing
“Nasakit nu
trauma common interventions, the frequent changes of discomfort and augments interventions, the
umanges nak” as
secondary to patient will be position, back rubs, and therapeutic effects of patient was able to
verbalized by the cause
patient.
CTT. able to report pain pillow support and etc. analgesia. report decreased pain
of cancer deat relief. relief as evidenced
Objective: h in men and -Schedule rest periods -Decreases fatigue and by:
women. Lung and provide quiet conserves energy,
-Restlessness cancer is the environment. enhancing coping abilities. Rated pain as: 5/10
carcinoma of
VS taken as -Assist with self-care -Prevents undue fatigue and
follows: the lungs char activities, breathing, arm incisional strain.
acterized by exercises and Encouragement and
-T: 36.8 uncontrolled ambulation. physical assistance and
growth of support may be needed for
-PR: 112
tissues of the some time before the patient
-RR: 24 lung. It usually is able or confident enough
to perform these activities
develops
-BP: 130/90 because of pain or fear of
within the wall pain.
-02Sat: 88% or epithelium
of the DEPENDENT
-Rated pain: 8/10 -Assist with patient- -Maintaining a constant
bronchial
controlled analgesia
tree. Its most drug level avoids cyclic
(PCA) or analgesia periods of pain, aids in
common through the epidural muscle healing, and
types are catheter. Administer improves respiratory
epidermoid intermittent analgesics function and emotional
routinely as indicated,
(squamous comfort and coping.
especially 45–60 min
cell) before respiratory
carcinoma, treatments, deep-
breathing or coughing
small cell (oat
exercises.
cell)
carcinoma,
adenocarcino
ma, and large
cell
(anaplastic)
carcinoma.
Although the
prognosis is
usually poor,
it varies with
the extent of
metastasis at
the time of
diagnosis and
the cell type
growth rate.
Lung cancer is
mostly
attributable to
the inhalation
of
carcinogenic
pollutants by
a susceptible
host. Any
smoker older
than 40,
especially if
the person
began to
smoke before
age 15, has
smoked a
whole pack or
more per day
for 20 years,
or works with
or near
asbestos.
Pollutants in
tobacco
smoke cause
progressive
lung cell
degeneration.
Lung cancer is
10 times more
common in
smokers than
in
nonsmokers.
Cancer risk is
 determined
by the
number of
cigarettes
smoked daily,
the depth of
inhalation,
how early in
life smoking b
egan, and the
nicotine
content of
cigarettes.

ASSESSMENT NURSING INFERENCE OBJECTIVES NURSING RATIONALE EVALUATION

DIAGNOSIS INTERVENTION
Subjective: Ineffective Cancer is a After the nursing Assist patient and Upright position favors After the nursing
airway clearance disease in which interventions, the instruct effective deep maximal lung expansion interventions, the
“Nahihirapan
related to cells in the body patient will be breathing and coughing and splinting improves the patient was able to
akong huminga” as
increased grow out of able to with upright position force of cough effort to demonstrate patent
verbalized by the
amount or control. When demonstrate (sitting) and splinting of mobilize and remove airway, with fluid
patient.
viscosity of cancer starts in patent airway, an incision. secretions. Splinting may be secretions easily
Objective: secretions. the lungs, it is with fluid done by the nurse (placing expectorated, clear
called lung secretions easily hands anteriorly and breath sounds, and
-Noisy respiration cancer. expectorated, posteriorly over chest wall) noiseless
Lung cancer clear breath and by the patient (with respirations.
VS taken as begins in the sounds, and pillows) as strength
follows: lungs and may noiseless improves.
spread to lymph respirations.
T- 36.7 nodes or other Suction if cough is weak “Routine” suctioning
organs in the or breath sounds not increases risk of hypoxemia
PR- 112 body, such as cleared by cough effort. and mucosal damage. Deep
the brain. Avoid deep tracheal suctioning is
RR- 25 Cancer from endotracheal or generally contraindicated
other organs nasotracheal suctioning following pneumonectomy
BP- 110/80 also may spread in pneumonectomy to reduce the risk of rupture
to the lungs. patient if possible. of the bronchial stump
02Sat- 89%
When cancer Suction the patient as suture line. If suctioning is
cells spread needed, and encourage unavoidable, it should be
from one organ beginning deep breathing done gently and only to
to another, they and coughing as soon as induce effective coughing.
are possible.
called metastase
s. Assess for pain or Encourages patient to move,
Lung cancers discomfort and medicate cough more effectively, and
usually are on a routine basis and breathe more deeply to
grouped into before breathing prevent respiratory
two main types exercises. insufficiency.
called small cell
and non-small Assist with incentive Improves lung expansion or
cell. These types spirometer, postural ventilation and facilitates
of lung cancer drainage and percussion removal of secretions.
grow differently as indicated. Postural drainage may be
and are treated contraindicated in some
differently. patients and in any event,
Non-small cell must be performed
lung cancer is cautiously to prevent
more common respiratory embarrassment
than small cell and incisional discomfort.
lung cancer.
Use humidified oxygen Providing maximal
and/or ultrasonic hydration helps loosen or
nebulizer. Provide liquefy secretions to
additional fluids via IV promote expectoration.
as indicated. Impaired oral intake
necessitates IV
supplementation to maintain
hydration.

Administer Relieves bronchospasm to

bronchodilators, improve airflow.
expectorants, and/or Expectorants increase
analgesics as indicated. mucus production and
liquefy and reduce the
viscosity of secretions,
facilitating removal.
Alleviation of chest
discomfort promotes
cooperation with breathing
exercises and enhances the
effectiveness of respiratory
therapies.