This document provides a case study of a 62-year-old female diagnosed with bronchogenic carcinoma. It includes sections on her client profile, nursing history, and physical examination findings. The nursing history covers her health patterns, habits, and lifestyle. The physical exam assessed her vital signs and performed a head-to-toe assessment, noting some abnormal lung findings on the left side consistent with her diagnosis.

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A CASE STUDY OF A 62 YEARS OLD, FEMALE
DIAGNOSED WITH
BRONCHOGENIC CARCINOMA
This Study is Presented to the
Faculty of San Lorenzo Ruiz School of Health Sciences
Mapúa Institute of Technology
Makati City
In Partial Fulfillment of the Requirements on
Curative and Rehabilitative Nursing Management 2
Part A (RLE)
Submitted to:
Prof. Ana Liza Manzanas
Prof. Mary Ann Nery
Prof. Leah Santillan
Prof. Delia Tan

2. Submitted by:
Adriano, Karen B.
Alejandro, Valery Benedict O.
Cabrera, Christianne S.
Cauntay, Immanuel Carlo L.
Galang, Jean Abegail B.
Indita, Ericxandria Ivi D.U.
Misa, Samuel Adrian A.
Racpan, Joana Lyn M.
Realco, Robert Daryl A.
Reyes, John Michael
AN01
September 18, 2009
1. CLIENT PROFILE
I. General Information
a. Name: Client RE
b. Hospital: Lung Center of the Philippines
i. Ward: 3C Ward
ii. Bed: Room 3305
c. Date of admission: July 28, 2009
d. Age: 62 years old
e. Birth date: July 23, 1947
f. Address: Kamuning, Quezon City
g. Occupation: Retired MMDA Officer
h. Educational Attainment: College Graduate
i. Spouse: n/a (Single)
j. Names of children, Ages, and educational attainment
 n/a
II.Chief Complaint
Upon admission, Patient complains of occasional Difficulty of Breathing.
III.Brief History of Present Hospitalization

3. Five (5) months prior to admission, patient had non-productive cough and
was negative for fever. Patient consultation was done and revealed to have
pulmonary mass (L) in CT-Scan. However, result was negative for the
presence of malignant cells.
Four (4) months prior to admission, patient still suffering for non-
productive cough and now associated with difficulty in breathing. Patient was
admitted and diagnosed with Pleural Effusion (L). Thoracentesis was done
and accumulated 355 mL of fluid. Days passed and she was discharged from
the institution.
Five (5) days prior to admission, patient was positive for anorexia,
experiences persistent nausea and vomiting, has intermittent non-productive
cough and occasional difficulty of breathing. Persistence of symptoms
accompanied by general body weakness led to consultation, hence admission.
IV. Medical Diagnosis
Bronchogenic Carcinoma, Left Pleural Effusion with Bronchial Asthma.
2. NURSING HISTORY
Last August 11, 2009, client RE was interviewed for her nursing history. This was
based on Gordon’s Functional Health Pattern which comprises of 12 different categories
used to provide more comprehensive nursing assessment for the client.
Starting with Health Perception and Health Management pattern, before the
hospitalization, client is working as an MMDA officer and her general health seems fine.
Accordingly, she was a blue baby (cyanotic), when she was born, the reason behind was
not noted by the client. Only now that she is old, she starts to have asthma. Her family
has a history of Blood Cancer and illness in the Pancreas. Right now that she is in the
hospital; she feels to have a big change and hope for her health. For the past 6 months,
she has been curing for the same illness. They don’t have any allergies to food. Same as
before, she eats nutritious foods to keep her body healthy. She neither engaged to
cigarettes, alcohol drinks nor illegal drugs. For the past 9 months, she is very cooperative
with Dr. Raymond, her physician. Before, she follows certain traditions like; a woman
who has monthly period should not eat sour foods and should take a bath using warm
water.
On Nutritional and Metabolic pattern, like before, she loves eating any foods except
Shrimp because her appetite doesn’t like it. For her 24-hour recall food consumption, she
had bread and milk for breakfast, she ate steamed ham sandwich for her lunch and a rice
and viand for her dinner. Her diet is as tolerated. She takes supplements like Vitamin B

4. Complex and Calcium Nitrate and even herbal tea. Before, she drinks 6 glasses of water
every day but currently, she only drinks 3 glasses of water every day, because lately, she
don’t get thirst easily. She used to have a good appetite before, but now, she losses her
appetite when she eats and experiences nausea. She does not have any eating discomforts
before, but recently she dislikes eating foul smelling foods especially seafoods, which not
her type of food. She does not have any diet restrictions and allergies to food as
mentioned above. Before, she weighs 60 kgs (132 lbs.) and stands 5 feet (150 cms.)tall.
Currently, she weighs 53 kgs (117 lbs) and still 5 feet tall. Her BMI is 22.8 kg/m2
, which
makes her height and weight appropriate for his age.
For her Elimination pattern, before she defecates twice (2) a day, the stool is yellow
brown in color, soft in consistency with no accompanying foul odor present and she does
not experience any discomfort. During hospitalization, she defecates once (1) a day, stool
is brown in color, soft to hard in consistency, with no foul odor present and she does not
experience any discomfort. For her urinary elimination, before she was hospitalized, she
urinates seven (7) times a day, approximately 250 milliliters per urination, with clear
color, no foul odor and no associated discomforts. During hospitalization, she urinates
four (4) times a day, still 250 milliliters per urination, yellowish in color and it smells like
medicine specifically the Antibiotics prescribed to her. She does not experience any
discomforts. Like before, she does not experience any excess perspiration and odor
problems.
On her Activity and Exercise pattern, she used to work and walk along the road as
MMDA officer every day, but now; she can only walk in her room, watch television and
read books. Before, she does not have sufficient energy in completing desired daily
activities, she experiences shortness of breath, and likewise in the hospital her energy is
not yet sufficient because she feels weak very easy. Since then, she does not have any
exercise pattern. Like what she used to do before, she watches television and takes nap
during spare time.
With regards on her Sleep-Rest pattern, before, she sleeps late at night (12:00 a.m.)
because she still watches television and wakes up 4:30 a.m. for her work on the next day.
She only sleeps 4 and a half hours with nightmares like “Bangungot”, being drowned and
in a fight. She takes quick naps during the day but it depends on her scheduled time of
duty that is why she doesn’t get enough rest. Right now, she sleeps 10 in the evening and
wakes up 6 in the morning. That makes her sleeping time 8 hours with no nightmares.
She takes naps during day and she does have enough rest in the hospital.
On Cognitive-Perceptual pattern, before she was hospitalized, she does not
experience any change in memory. The easiest way for her to learn things is through
reading and watching television. She does not have any hearing difficulty. She do
experience difficulty in reading small letters in books other than that she does not have
any visual disturbances. Her last eye checked up examination was done before at her
work. During hospitalization, she do experience change in memory and she believes it is
due to the anesthesia effect, she had on her previous operations. It is easy for her to learn
still through reading books and newspaper and watching television. She still doesn’t have

5. any hearing difficulty. She still experience difficulty in reading small letters in books
other than that she still does not have any visual disturbances.
For Self –Perception and Self-Concept pattern, before the hospitalization, client
describes herself, healthy with accurately balanced weight but now that she is
hospitalized she stated that her weight decreased and she looks much thinner than before.
There has been so much change in her body including her weight and strength. Before,
she used to work every day but now, all she can do is to lie in the bed and keep her body
healthy. Before, she gets annoyed easily when she relaxes and her niece/nephews will
jump into the bed and disturb her. Right now, she feels annoyed when she smells foul
smelling odor foods like left over foods on her room, but to her condition, she feels
saddened about it.
On Role-Relationship pattern, she lives with her parents’ house with her brother and
niece/nephews. They have an extended family structure. According to her before
hospitalization, she has no difficulty in handling problems, their family usually handle
their problems by talking about it. For her social life, she has few friends and she doesn't
belong to any social groups. During her hospitalization, she is trying to accept and deal
with her problem especially her sickness. Her family deals the problem by just accepting
the fact about her illness. She has close friends who visits her in the hospital and she does
not belong to any social groups.
For Home and Environment pattern, client describes their home as a small house with
1 floor and 2 rooms both made in cement and wood. The toilet can be seen near their
rooms. Their garbage trash is near their house. She describes her neighborhood as a clean
city and free from any harm, easily accessible to the hospital and church but far from
malls, any markets, factories. She describe her neighbors as all rich but still manage to
chat with each other at their free time.
On Sexuality and Reproductive pattern, her menstruation started when she was 12
years old and her last menstrual period was in her early 50's. Before her menopausal
period, she menstruates regularly, for about 3 days with an amount of 150 milliliter per
month consuming 2-3 pads per day and she does experience dysmenorrhea. She doesn’t
have any menstrual problems and her Obstetric score is GTPAL 0(0000).
For Coping-Stress Tolerance pattern, the illness she had was the big change in her
life. She lost her dreams of travelling to places after she learned about her disease. Before
her hospitalization and during hospitalization, she manages her stress by drinking water
and taking enough rest. She handles her problems by praying to God and all conflicts
happened to her life went successful.
Lastly, on Value-Belief pattern, the most important thing in her life is her parents.
She is a Catholic and what she believes is so important to her. Before hospitalization, she
regularly attends mass every Sunday but now that she is in the hospital, she sends
offertory prayers for her fast recovery in every mass. These things do really help for her
condition because she strongly believes in it.

6. 3. PHYSICAL EXAMINATION
Client RE was given a head-to-toe physical assessment last August 11, 2009. The
assessment provided baseline data that were indicative of the client’s functional abilities.
The data obtained will help establish appropriate nursing diagnoses and plan of care for
the client.
Starting from her baseline data, we recorded her height at 5 feet (150 cm), her weight
at 53 kg (117 lbs), her temperature at 36°C taken from her left axillary, her pulse rate at
87 beats per minute from her left radial pulse with a regular rhythm, her respiratory rate
at 27 breaths per minute, and her blood pressure at 110/80 on her left arm while she was
seated.
For her general appearance, client RE was dressed in pajamas and well groomed
during the interview. She has a medium frame body build. She did not have any apparent
odor or physical deformity. She spoke comfortably while sitting up in bed. The client
chose to sit up in bed rather than to transfer to a chair because she stated that she easily
feels tired.
For her mental status, client RE was conscious and oriented to time, place and person.
Moreover, she was cooperative and had a pleasant mood. She used simple words and
communicated well.
Integumentary system was assessed. Her skin color was normal (brown, warm, dry
and smooth). Her skin turgor was elastic and mobile. Her hair was evenly distributed and
her nails were convex and ridged. Her capillary refill was 3 seconds. There was no
edema present.
For the client’s head and face, her skull is proportionate to her body size
(normocephalic), her scalp is clean and her face is symmetrical. Upon asking the client,
to puff her cheeks, raise her eyebrows, frown, and smile, it was revealed that her facial
movement was symmetrical.
Her eyes are straight and normal, eyebrows are thin, eyelids and eyelashes have
effective closure. The eyelashes are thin with a length of 1 cm. She has a negative
discoloration on her periorbital region. Her blink response is bilateral and positive. Her
eyeballs were symmetrical. Her sclera was white and her pupils were equal with a size of
3 mm. Her bulbar conjunctiva are clear and her palpebral conjunctiva are pinkish. Both
her left and right eye had a brisk reaction to light and accommodation. She has good
peripheral vision and six ocular movements. Her visual acuity is abnormal for she was
unable to recognize the words 12 to 14 inches away. Her lacrimal gland was non-tender
upon palpation. Her lacrimal apparatus was moist.

7. Her ears have normal (brown) racial tone, normoset, symmetric and elastic. The pinna
recoils when folded, has no signs of lesions and no signs of inflammation. The external
canal has some cerumen present. Her hearing acuity is normal for she responds to normal
voice. Her ears are symmetrical for gross hearing and whisper test. There are no signs of
AD, AS or AU difficulty.
Her nose, externally, has a normal (brown) racial tone. Her nasolabial fold is
symmetrical. The septum is in midline. Mucosa of the nose is pale. The client still has a
nasal cannula with a flow rate of 7-10 LPM. The nasal cavity is dry and the sinuses are
non - tender. Both right and left nostrils are patent and able to distinguish two scents.
For her mouth, client’s lips are pale and symmetrical, the mucosa is pink; the tongue
is in midline, rough and pink. The client has dentures because her teeth are incomplete.
Her gums are pale. The speech is intact.
For her pharynx, her uvula is in midline position. Tonsils are not inflamed. Posterior
pharynx is not inflamed. Hard and soft palates are pinkish and non-tender. Her gag reflex
was present.
For her neck, neck muscle is equal in size, muscle strength is 5/5, which is strong
against resistance, and lymph nodes on the neck area are not palpable. The trachea is
midline. Thyroid gland is non-palpable.
For the client’s breast and axillae, her breasts are asymmetrical; the left breast is
slightly bigger than the right, round in shape. Skin is normal in color, with no redness,
edema or prominent veins. Breast is non-tender. Nipple and areola are not inverted, no
edema, retraction, deviation and discharges. Lymph nodes are not palpable.
For her chest and lungs, breathing pattern is tachypnic, shallow and use of accessory
muscles during inspiration was present. She has 27 breathes per minute (since normal
breathing pattern is 16-20 breathes per minute). She has a nasal cannula attached to her
nostrils with flow rate of 7-10 LPM. AP lateral ratio is 1:2. Inspiration to expiration is
1:3. There were no bulges or tenderness upon palpation. Tactile fremitus was revealed to
be asymmetrical; the tactile fremitus of the right lung is stronger than the tactile fremitus
of the left lung which is decreased. Further assessment was done on the left lung field in
addition to the tactile fremitus examination, bronchophony revealed clear sound;
egophony revealed “aaa” sound; and whispered pectoriloquy revealed clear sounds in
which all findings were abnormal. Upon percussion, her right lung had a resonant sound
while percussion of the left lung revealed a dull and flat sound. Normal breath sounds
(bronchial, bronchovesicular and vesicular) were present on the right lung field but were
consolidated on the left lung field (crackles and wheezes breath sounds), the bronchial
sound could be heard in the peripheral areas of the lung. Lung expansion is asymmetrical
in both anterior and posterior areas with both lag.

8. For her heart, her precordial area is flat and normodynamic. The point of maximal
impulse is best heard at the 5th intercostal space, midclavicular line. The heart sounds
were distinct with 86 beats per minute.
For her abdomen, her skin is normal in racial tone. There were no lesions noted on
her skin. Her umbilicus is sunken. Moreover, the configuration is flat in shape and has
symmetrical movement. The abdomen is non – tender and the liver is palpable upon
bimanual palpation. There is no fluid wave, the client is normotensive and the sound
upon palpation is tympanitic. Bowel movements were normal with 11 bowel sounds per
minute, discharge of fecal matter occurred earlier. Food intake was allowed. Bladder was
empty & relaxed.
Client RE’s genital area was not assessed due to personal reasons; the choice of the
client was respected by the nurses.
Lastly, for her back and extremities, her nine peripheral pulses were symmetrical,
strong, and regular. Her joints were not inflamed and she was able to perform active
range of motion exercises on both extremities but with slowed movement. Her upper
extremities were mobile and normal tone however she had weakness with muscle
strength of 3/5. There were no tenderness, no lesions found and no other deformities
present. Client had a heplock attached to his left hand; site is intact and negative for signs
of inflammation. Lymph nodes were not palpable in the upper extremities. For her lower
extremities, it was also mobile with a normal tone however with muscle weakness grade
of 3/5, lymph nodes were not palpable. There were neither lesions nor any other
deformities found in the lower extremities. Her spine was the midline and was negative
for the costovertebral angle punch and pain in dorsiflexion. Lesion from the clients’
thoracentesis was present on the posterior 6th
intercostals space.
4. ANATOMY AND PHYSIOLOGY
Anatomy of the Lungs
The trachea (windpipe) branches into two smaller airways: the left and right
bronchi, which lead to the two lungs. The left lung is longer, narrower, and has a smaller
volume than the right lung it shares space in the left side of the chest with the heart. The
right lung is divided into three lobes and each lobe is supplied by one of the secondary
bronchi. It has an indentation, called the cardiac notch, on its medial surface for the apex
of the heart. The left lung has two lobes.
The bronchi themselves divide many times before branching into smaller airways
called bronchioles. These are the narrowest airways – as small as one half of a millimeter
across. The larger airways resemble an upside-down tree, which is why this part of the
respiratory system is often called the bronchial tree. The airways are held open by

9. flexible, fibrous connective tissue called cartilage. Circular airway muscles can dilate or
constrict the airways, thus changing the size of the airway.
At the end of each bronchiole are thousands of small air sacs called alveoli.
Together, the millions of alveoli of the lungs form a surface of more than 100 square
meters. Within the alveolar walls is a dense network of tiny blood vessels called
capillaries. The extremely thin barrier between air and capillaries allows oxygen to move
from the alveoli into the blood and allows carbon dioxide to move from the blood in the
capillaries into the alveoli.
Each lung is enclosed by a double-layered serous membrane, called the pleura.
The visceral pleura is firmly attached to the surface of the lung. At the hilum, the visceral
pleura is continuous with the parietal pleura that lines the wall of the thorax. The small
space between the visceral and parietal pleurae is the pleural cavity. It contains a thin film
of serous fluid that is produced by the pleura. The fluid acts as a lubricant to reduce
friction as the two layers slide against each other, and it helps to hold the two layers
together as the lungs inflate and deflate.
The lungs are soft and spongy because they are mostly air spaces surrounded by
the alveolar cells and elastic connective tissue. They are separated from each other by the
mediastinum, which contains the heart. The only point of attachment for each lung is at
the hilum, or root, on the medial side. This is where the bronchi, blood vessels,
lymphatics, and nerves enter the lungs.
Figure 1. Anatomy of the Lungs

10. 5. PATHOPHYSIOLOGY
Theoretical – Based PathophysiologyFigure 2. Lung Oxygenation
Smoking
Polymorphisms in
genes coding for
interleukin-1
Primary Tumor Arises
Periphery of
Lung
Invasion of Pulmonary
Membranes and
Vasculature
Terminal
Airway
Obstructio
n
Compression
Dyspnea
Pleural
Effusion
Atelectasis
Precipitating Factors Predisposing Factors
Occupational
Exposure
Asbestos
Radon
Mutations in the
K-ras proto-
oncogene

11. Patient – Based Pathophysiology
Precipitating factor
Occupational
Exposure (MMDA
Officer)
Exposure to
Second-Hand
Smoke
Primary tumor arises in the periphery of the lungs
Hypermetabolic state
from cell proliferation is
induced by the tumor’s
growth needs
Weakness
Terminal airway
obstruction
Dyspnea,
occasionally
nonproductive cough
Invasion of
pulmonary
membranes and
vasculature.
Increased
Permeability of the
pleural space
355 cc of serous
fluid leaks into
the pleural space
Hydrothorax
Restricted Lung
Expansion.
Shallow
Respirations
Imbalanced oxygen
supply and demand
Pleural fluid
accumulates
Secondary
infection of
Pneumonia
Weight loss

13. 6. DRUG STUDIES
Drug Order
Drug
Classification
and
Mechanism of
Action
Indications
Contra-
indications Adverse Effects
Desired Actions
Nursing Responsibilities
Generic
Name:
Piperacillin +
Tazobactam
Brand
Name:
Piptaz
Dosage:
4.5 grams
Frequency:
Q8
Route:
TIV
Classification:
Extended
spectrum
Penicillin, Beta-
lactamase
inhibitor
Mechanism of
Action:
Inhibits cell
wall synthesis
during bacterial
multiplication.
Moderate to
severe
secondary
infection of
pneumonia.
 Hyperse
nsitivity
to drug
and
other
penicilli
ns.
No adverse effect
noted on client,
however, the
following should be
monitored and
reported:
 Headache
 Insomnia
 Fever
 Agitation
 Dizziness
 Hypertension
 Tachycardia
 Chest pain
 Edema
 Rhinitis
 Diarrhea
 Nausea
 Constipation
 Vomiting
 Dyspepsia
 Stool changes
 Abdominal
To free the client
from infection.
Before giving drug, ask
the patient about allergic
reactions to penicillins.
Watch out for any super
infections when large
doses are given and if
therapy is prolonged,
especially in elderly and
immunosupressed
patients.
Tell patient to alert a
health care professionals
about discomfort at the IV
site.

14. pain
Drug Order
Drug
Classification
and
Mechanism of
Action
Indications Contra-
indications
Adverse Effects Desired Actions Nursing
Responsibilities
Generic
Name:
Cephalexin
Brand
Name:
Keflex
Dosage:
500 mg/cap
Classification:
First generation
Cephalosporins
Mechanism of
Action:
It inhibits cell
wall synthesis,
promoting
osmotic
instability,
usually
Respiratory
tract
infections
 Hypersen
sitivity to
cephalosp
orins.
No adverse effect
noted on client,
however, the
following should be
monitored and
reported:
 Headache
 Dizziness
 Fatigue
 Confusion
 Hallucinations
To treat the
respiratory tract
infections.
Use cautiously in
patients hypersensitive
to penicillin because of
possible cross-
sensitivity with other
beta-lactam antibiotics.
Tell to take drug exactly
as prescribed, even if
she feels better.
Instruct to take drug
with food to lessen GI

15. Frequency:
TID
Route:
PO
bactericidal  Anorexia
 Diarrhea
 Nausea
 Vomiting
 Anemia
 Maculopapular
Rash
discomfort.
Tell to notify physician
if rash or any signs and
symptoms of
superinfections develop.
Drug Order
Drug
Classification
and Mechanism
of Action
Indications Contra-
indications
Adverse Effects
Desired
Actions
Nursing
Responsibilities
and Precaution
Generic Name:
Hyoscine N-
Butylbromide
Brand Name:
Buscopan Plus
Dosage:
500 mg/1 tab
Frequency:
Classification:
Antispasmodic
Mechanism of
Actions:
Inhibits
muscarinic
actions of
acetylcholine on
autonomic
effectors
innervated by
Paroxysmal
pain in chest.
 Hypersensitive to
belladonna or
barbiturates
 Angle-closure
glaucoma
 Obstructive
Uropathy
 Obstructive
disease of GIT
 Myasthenia gravis
 Paralytic ileus
 Intestinal atony
 Unstable CV
status in acute
No adverse effect
noted on client,
however, the
following should be
monitored and
reported:
 Disorientation
 Restlessness
 Irritability
 Drowsiness
 Headache
 Confusion
 Hallucination
To relief
paroxysmal
or spastic
pain.
Advise to take
the drug after
meals
Raise side rails
as a precaution
because some
patients become
temporarily
excited or
disoriented and
some develop
amnesia or
become drowsy.

16. TID
Route:
PO
postganglionic
cholinergic
neurons.
hemorrhage
 Tachycardia from
cardiac
insufficiency
 Delirium
 Impaired
memory
 Palpitations
 Tachycardia
 Flushing
 Blurred vision
 Difficulty
swallowing
 Constipation
 Dry mouth
 Nausea
 Vomiting
Reorient patient,
as needed.
Warn patient to
avoid activities
that requires
alertness until
CNS effects of
drug are known.
Monitor I & O
for urinary
retention.
Drug Order
Drug
Classification
and Mechanism
of Action
Indications
Contra-
indications Adverse Effects
Desired
Actions
Nursing
Responsibilities
and Precaution
Generic Name:
Esomeprazole
Brand Name:
Nexium
Dosage:
40mg/tab
Classification:
Proton pump
inhibitor
Mechanism of
Actions:
Suppress gastric
secretion by
inhibiting
Hydrogen
Potassium
ATPase enzyme
Prevention of
duodenal and
gastric ulcers
 Hypersensitive to
drug long term
administration of
bicarbonate with
calcium or milk
will cause milk
alkali syndrome
No adverse effect
noted on client,
however, the
following should be
monitored and
reported:
 Weight loss
 Recurrent
vomiting
 Dysphagia
 Angina
 Tachycardia
To prevent
gastric upset
since client
is taking
antibiotics
which may
aggravate
gastric
discomforts.
Assess GI
system. Bowel
sound 8 hours,
pain abdomen &
smelling,
appetite loss.
Should be taken
before breakfast.
Patient may
experience
anorexia, small

17. Frequency:
OD
Route:
PO
system in the
gastric parietal
cell characterized
as a gastric acid
pump inhibitor
since it blocks the
final step of acid
production.
 Bradycardia
 Headache
 Dizziness
 Rash
 Diarrhea
 Abdominal
pain
 Nausea
 Acid
regurgitation
frequent meals
may help to
maintain
adequate
nutrition.
Report severe
headache
diarrhea,changes
in respiratory
status.
Drug Order Drug Classification
and Mechanism of
Action
Indications Contra-
indications
Adverse Effects Desired
Actions
Nursing
Responsibilities
Generic Name:
Tramadol +
Paracetamol
Brand Name:
Dolcet
Dosage:
325 mg/1 cap
Classification:
Non Opoid Analgesic
Mechanism of
Actions:
It inhibits the reuptake
of norepinephrine and
serotonin.
Paracetamol has
analgesic activity.
Moderate to
severe pain
 Hypersensiti
vity to drug
or other
opiods
 Acute
Intoxication
 Alcohol
hypnotics
 Centrally
acting
analgesics,
opiods
 Psychotropi
No adverse effect
noted on client,
however, the
following should be
monitored and
reported:
 Dizziness
 Headache
 Vertigo
 Anxiety
 Confusion
 Malaise
To relief
moderate to
severe pain.
The nurse should know
that serious
hypersensitivity
reactions can occur,
usually after the first
dose.
Reassess patient’s level
of pain at least 30
minutes after
administration.
Monitor respiratory

18. Frequency:
Q6
Route:
PO
Used together,
tramadol and
paracetamol has faster
onset of action
compared to tramadol
alone and longer
duration of action
compared to
paracetamol alone
c drugs.
 Patients
with of
anaphylactic
reaction to
codeine and
other opiods
maybe at
increase risk
 Nervousness
 Sleep
disorder
 Constipation
 Abdominal
pain
 Anorexia
 Diarrhea
 Dry mouth
 Flatulence
 Urine
retention
 Repiratory
depression
status. Withhold dose
and notify Prescriber if
respirations decrease or
rate is below 12
breaths/min.
Monitor bowel and
bladder function.
Anticipate need for
laxatives.
For better analgesic
effect, give drug before
onset of intense pain.
Drug Order
Drug Classification
and Mechanism of
Action
Indications Contra-
indications
Adverse Effects Desired
Actions
Nursing
Responsibilities and
Precaution
Generic Name:
Levodropropizine
Brand Name:
Levopront
Dosage:
10 cc/syrup
Frequency:
Classification:
Mucolytics
Mechanism of Action:
Levodropropizine is a
cough suppressant that
exerts peripheral action
in nonproductive cough
Non-
productive
cough
 Contraindic
ated in
patients
with
excessive
mucus
discharge
and limited
mucociliary
function
 Severe
Liver
Impairment
No adverse effect
noted on client,
however, the
following should be
monitored and
reported:
 Nausea
 Vomiting
 Heartburn
 Diarrhea
 Weakness
 Drowsiness
To clear the
airway. The drug should be
kept in below 30o
C.
Tell the patient to take
the drug between
meals.
Teach client deep
breathing exercises.
Maintain adequate
hydration status.

19. TID
Route:
PO
 Dizziness
 Headache
 Palpitations
Tell patient to report
immediately to health
care provider if allergic
reactions develop such
as nausea, vomiting,
drowsiness, weakness.
7. DIAGNOSTIC STUDIES

20. Name of
Procedure
Date
Done
Indication for the Test or
Procedure
Normal Values,
Results or
Findings
Actual Results or Findings
Interpretation and
Significance of the Results
or findings
Pleural
Fluid
analysis
(Cytology
Report)
08/03/09  This is often done when a
mesothelioma or
metastatic cancer is
suspected. The presence
of certain abnormal cells,
such as tumor cells or
immature blood cells, can
indicate what type of
cancer is involved.
Normal structure of
cells. No detectable
presence of
abnormal cells like
cells or immature
blood cells.
 Received approximatley
500ml of brownish yellow,
turbid fluid with coagulum
and labeled as “pleural
Fluid”.smears and cell
blocks were prepared.
 Smears shows collections
of varisized lymphocytes
and scanty atypical cells
dispersed on a pale
proteinaceous background
while the cell block yielded
polygonal cells with round,
hyperchromatic nuclei,
occassionally prominent
nucleoli, and ample cyto
plasm, disposed in acini
and fluorettes.
Cytomorphologic features
consistent with
adenocarcinoma.
Pleural
biopsy
(Surgical
Pathology
Report)
07/09  To check for the
condition of the lungs,
heart related lung
problems, the size and
outline of the heart and to
check blood vessels
All organs in the
chest are normal in
appearance
 The specimen consists of a
tan white, soft, irregularly
shaped tissue fragments
measuring .5x.4x.1 cm and
labeled as “left pleura.”
block all.
 Microscopic examination
shows fibromascular tissue
and a fragment of
fibrocollagneous tissue
infiltrated by a malignant
neoplasm composed of
polygonal cells with
hyperchromatic, round
nuclei, and ample
cytoplasm disposed in
small nests and associated
with inflammatory cells.
Non Small Cell Carcinoma
Tumor 02/12/09

22. 8. PRIORITIZATION OF NURSING DIAGNOSIS
Rank Problem Rationale
1
Ineffective Airway
Clearance related to
terminal airway obstruction
Maintaining a patent airway
is vital to life. Loss of
respiratory function would
be life – threatening.
2
Ineffective Breathing
Pattern related to terminal
airway obstruction
secondary to pleural
effusion
According to the ABC rule
of emergency care,
problems with breathing
should be checked after
ensuring a patent airway
since this is a life-
threatening problem.
3 Activity Intolerance related
to imbalance of oxygen
supply and demand
Treatment of her high
priority problem
(Ineffective Airway
Clearance) will relieve one
of the etiologies of this
problem.
4
Anxiety related to
difficulty in breathing and
concerns over work
Treatment of her high
priority problem
(Ineffective Airway
Clearance) will relieve one
of the etiologies of this
problem.
5
Sleep pattern disturbance
related to difficulty in
breathing
Treatment of the problems
in breathing and airway
clearance would solve this
problem. Therefore, this
problem would have to be
attended after the nurse has
improved the client’s
airway clearance and
oxygenation.

24. 9. NURSING CARE PLANS
PRIORITY #1
CUES NURSING
DIAGNOSIS
SCIENTIFIC
EXPLANATION
AND
BACKGROUND
PLANNING INTERVENTIONS RATIONALE EVALUATION
Subjective:
“Hirap ako
huminga,” as
verbalized by
the client.
Objectives:
 With nasal
cannula
with a flow
rate of 7-10
LPM.
 Dyspnea
 Occasional
non
productive
cough
 Difficulty
of
breathing
 Ct scan
result:
Ineffective
Airway
Clearance
Related to
Terminal
Airway
Obstruction
Presence of tumor
Partial obstruction
of bronchus
Ineffective airway
clearance
Goal: After 2
weeks of
nursing
intervention the
patient will
maintain airway
patency.
Objectives:
After 8 hours of
nursing
intervention the
patient will:
 Verbalize
understandin
g of cause
and
therapeutic
management
regimen
 Position head
midline with
flexion
appropriate for
age/ condition.
 Elevate head of
the bed/ change
in position
every 2 hours
and prn.
 Assist in
administering
oxygen via
nasal cannula.
 Encourage deep
breathing and
coughing
exercise
 To open or
maintain
airway.
 To take
advantage of
gravity
decreasing
pressure on
the
diaphragm .
 To improve
ventilation.
 To
maximize
effort in
breathing/
After intervention
was done the
patient:
 The goal was
met the patient
demonstrated
behaviors to
improve
airway
patency
 Verbalized
understanding
of cause and
therapeutic
management
regimen
RR: 16-20
breathes/min.

25. presence of
pulmonary
mass
 Shortness
of breath
 Shallow
respirations
 Decreased
tactile
fremitus on
left lung
field
 RR: 27
breathes/
minute
 Demonstrate
behaviors to
improve
airway
patency
 Administer
analgesics as
ordered
 Auscultate
breath sounds
 Monitor vital
signs especially
respiratory rate
 Observe signs
of respiratory
distress
 Provide
opportunities
for rest, limit
activities to
level of
respiratory rate
 To improve
cough when
pain is
inhibiting
effort/
 To ascertain
status and
note
progress/
 To assess
changes/
complicatio
ns.
 To assess
complicatio
ns.
 To prevent
fatigue.

26. PRIORITY #2
CUES
NURSING
DIAGNOSIS
SCIENTIFIC
EXPLANATION
AND
BACKGROUND
PLANNING INTERVENTIONS RATIONALE EVALUATION

27. Subjective:
“Nahihirapan
akong
huminga” as
verbalized by
the client
Objective:
 (+) use of
accessory
muscles for
breathing
 With nasal
cannula
 (+) dyspnea
 (+)
shortness of
breath
anddifficult
y of
breathing
 RR: 27
breathes/
minute
Ineffective
Breathing
Pattern related
to terminal
airway
obstruction
secondary to
pleural effusion
Presence of tumor
in left lung
Increased in level
of pleural fluid
amylase
Increased
capillary
permeability or
vascular
disruption
Reduction of
pressure in pleural
space; lung is
unable to expand
Pleural effusion
Obstruction of
Goal: After1
week of nursing
intervention, the
client’s
respiratory
status,
ventilation, and
respiratory rate
will be within
normal ranges as
manifested by
improved
respiratory
status and
ventilation and
respitatory rate
of 16 to 20
breaths per
minute.
Objectives:
After 3 days of
Nursing
Intervention, the
client will be
able to:
 Demonstrate
pursed lip
breathing
 Report
ability to
 Monitor
respiratory rate,
depth, and ease
of respiration
 Note abdominal
breathing, use of
accessory
muscles for
breathing, nasal
flaring,
retractions,
irritability,
confusion, or
lethargy
 Observe color of
tongue, oral
mucosa and skin
 Auscultate
breath sounds
 To
determine
the pattern
of
respiration
of the client
 These
symptoms
signal
increasing
respiratory
difficulty
and
increasing
hypoxia
 Cyanosis of
the tongue
and oral
mucosa is
central
cyanosis and
generally
represents an
medical
emergency
 The
abnormal
After 1 week of
nursing
interventions, the
client:
 Respiratory
status,
ventilation,
and
respiratory
rate are in
normal
ranges as
manifested by
improved
respiratory
status and
ventilation
and
respiratory
rate of 16 to
24 breaths
per minute
 Demonstrated
pursed lip
breathing
 Reported
ability to
breathe
comfortably

28. terminal airway
obstruction
Ineffective
breathing pattern
breathe
comfortably
 Identify and
avoid
specific
factors that
exacerbate
episodes of
ineffective
breathing
pattern
noting decreased
or absent breath
sounds, crackles,
or wheezes
 Position the
client in an
upright or semi-
fowlers position
 Administer
ordered oxygen
via nasal
cannula.
 Encourage client
to take deep
breaths at
prescribed
intervals and do
controlled
coughing
 Teach pursed lip
and controlled
breathing
lung sounds
can indicate
respiratory
pathology
associated
with an
altered
breathing
pattern
 An upright
position
facilitates an
lung
expansion
 Oxygen
therapy
helps
decrease
dyspnea
 To help
relax the
client
 Pursed lip
breathing
increases
 Identified and
avoided
specific
factors that
exacerbate
episodes of
ineffective
breathing
pattern

29. exercises
 Teach the client
to identify and
avoid specific
factors that
exacerbate
ineffective
breathing
patterns
use of
intercostals
muscles,
decreased
respiratory
rate and
improve
oxygen
saturation
 So the
client will
know the
factors that
might
affect the
breathing
pattern

30. PRIORITY #3
Cues Nursing
Diagnosis
Scientific
Explanation
Planning Interventions Rationale Evaluation
Parameters
Subjective:
 “Madali
akong
mapagod
kaya lagi
lang akong
nakahiga at
nakaupo,
kaya
minsan la
na ko
kagana
ganang
maglakad”
as
verbalized
by the
client.
Objective:
 weakness
on upper
and lower
extremities
(3/5 muscle
strength)
 Inability to
begin or to
perform
Activity
Intolerance
Related to
imbalanced
oxygen
supply and
demand
Presence of
tumor in the
left lung
Invasion of
pulmonary
membranes
and
vasculature
Restricted
lung
expansion
Imbalanced
oxygen supply
and demand
Weakness,
fatigue,
dyspnea,
tachypnea
Activity
intolerance
Goal:
After 1 week of
intervention,
the client will
demonstrate
decrease in
physiological
signs of
intolerance.
Objectives:
After 8 hours
of intervention,
the client will:
a. maintains
activity level
within
capabilities
b. verbalize and
use energy-
conservation
techniques
c. participate to
treatment
regimen within
 Determine
patient's
perception of
causes of
fatigue or
activity
intolerance
 Assess
nutritional
status
 Establish
guidelines
and goals of
activity with
the patient
and caregiver
 Provide
bedside
commode as
indicated
 These may be
temporary or
permanent,
physical or
psychological
Assessment
guides
treatment.
 Adequate
energy
reserves are
required for
activity.
 Motivation is
enhanced if
the patient
participates
in goal
setting.
 This reduces
energy
expenditure.
NOTE: A
bedpan
requires more
After the
intervention, the
client
demonstrated
decrease in
physiological
signs of
intolerance and
was able to
conserve energy
and client
participated to
treatment
regimen.

31. activity
 Dyspnea
 RR= 27
breaths per
minute
(tachypnea)
 Shallow
respirations
 Lack of
interest in
activity
level of
situation.
 Administer
medications
as indicated
 Health
teaching
about ROM
and
strengthening
exercises
and
importance of
it.
energy than a
commode.
 To treat
underlying
condition.
 To strengthen
body, assess
capabilities
and also for
client’s
understandin
g of his
treatment
regimen.

32. 10. DISCHARGE PLAN
M – edications
Medications taken at home should include and be centered on antibiotics, pain
killers, mucolytics, bronchodilators, anti-emetics and especially dietary supplements such
as:
 Tramadol + Paracetamol - for Moderate to Severe Pain.
325 mg/1 cap, Q6, PO
 Levodropropizine - for cough suppressant.
10 cc/syrup, TID, PO
 Cephalexin - to treat infections
500 mg/cap, TID, PO
 Hyoscine N- Butylbromide for Spastic Pain
500 mg/tab, TID, PO
 Esomeprazole for treatment of possible gastric and duodenal ulcer since
client takes antibiotics.
40 mg/tab, OD, PO
Exercise
Activity is as tolerated and actually according to physicians advised. While there
are many reasons for being physically active during cancer treatment, client’s exercise
program should be based on what is safe, effective, and enjoyable for the client.
Exercises should take into account any exercise program that the client already follows,
what she can do now, and any physical problems or limits she may have. She and her
doctor should tailor an exercise program to meet her interests and needs. While some
people can safely begin their own exercise program, many will have better results with
the help of an exercise specialist, physical therapist, or exercise physiologist. Be sure to
get an approval from client’s doctor first. The goal is to have an exercise program that
will help client maintain endurance, muscular strength, flexibility, and level of
functioning and most especially prevention of fatigue.
To make client’s exercise most effective, it is important to emphasize that she
should work her heart. They should pay attention to her heart rate, breathing, and how
tired muscles get. Start slowly at first, and over the next few weeks, increase the length of
time of exercise. The best level of exercise for someone with cancer has not been
established. However, the more exercise, the more ability to exercise can improve the
ability to function effectively.
 Start slowly with an exercise program. Even if client can only do an activity for a
few minutes a day it will help her. How often and how long she will do a simple
activity like walking can be slowly increased.

33.  Try short periods of exercise with frequent rest breaks. For example, walk briskly
for a few minutes, slow down, and walk briskly again, until she have done 30
minutes of brisk activity. She can divide the activity into three 10-minute
sessions, if this is the way to prevent fatigue.
 Try to include physical activity that uses large muscle groups. Strength,
flexibility, and aerobic fitness are all important parts of an exercise program that
works.
 Always start with warm-up exercises for about 2 to 3 minutes. Examples of
warm-up exercises are shoulder shrugs, lifting arms overhead, toe tapping,
marching, and knee lifts. End session with stretching or flexibility exercises. Hold
the stretch for about 15 to 30 seconds and relax. Remember to breathe when
stretching to relax all the muscle groups.
 Exercise moderately.
Treatment
Chemotherapy was planned for the client since she was recently admitted.
Chemotherapy treatments may be given in the hospital, doctor’s office or clinic. They are
usually given in cycles (such as monthly or weekly) so that the body can rest and repair
between cycles. Treatment schedules vary for each patient. A doctor called a medical
oncologist will decide what type of chemotherapy will the client receive and how often it
should be given. For this reason it is very important to follow the treatment plan exactly
and keep all appointments.
Aside from chemotherapy, the medications ordered should be emphasized
because it is considered as a treatment as well.
Health Teaching
Health teaching should comprise of effective medications and treatment, diet,
exercises, possible side effects monitoring and most especially, ways to prevent
development of fatigue. Most cancer patients notice a loss of energy therefore increase
susceptibility to develop fatigue.
Tips to reduce fatigue:
 Tell the client to set up a daily routine that allows activity when she is feeling at
her best.
 Exercise regularly at light to moderate intensity (see suggestions above at exercise
section)
 Get fresh air.
 Unless it is advised by the physician, emphasize to client to eat a balanced diet
that includes protein (meat, milk, eggs, and legumes such as peas or beans) and
drink about 8 to 10 glasses of water a day.
 Keep symptoms such as pain, nausea, or depression controlled.

34.  To save energy, keep things that are use often within easy reach.
 Enjoy hobbies and other activities that gives pleasure.
 Use relaxation and visualization techniques to reduce stress.
 Balance activity with rest that does not interfere with nighttime sleep.
 Most especially, ask for help when needed.
OPD Follow-Up
OPD follow-up is always after 1-2 weeks after discharge. If the client was
discharged on September 5, 2009, the client should have a follow-up examination on
September 12, 2009, 8AM at OPD department of lung center under Dr. Raymond.
The succeeding follow-up should be based on her chemotherapy schedules.
Diet
Clients with cancer were usually advised to have diet as tolerated, no food
restrictions recommended. Good nutrition is important for all of us, but during treatment
it is especially important. Maintaining a high intake of calories and protein can prevent
body tissue from breaking down and can help rebuild healthy tissue after treatment. The
treatments target fast-growing cells found in the lining of the mouth and the digestive
system. Damage to these healthy, fast-growing cells may cause some side effects that
lead to eating problems.
With good nutrition client can:
 Prevent or reverse weight loss
 Tolerate therapy with fewer side effects
 Keep body in the best physical condition to fight infection
 Give body a chance to repair normal tissues damaged by chemotherapy and
radiation
 Have more energy for a quicker recovery
 Feel better
Accentuate to client the following:
 Eating small, frequent meals throughout the day.
 Keeping snacks on hand and eating them whenever she feels like it. Remember to
take a snack with her if she is going to be away from home for an extended length
of time.
 If she don’t feel like eating solid foods or food seems to grow the more she chew
it, try liquids such as juice, soup or milkshakes with a straw. Liquid and powdered
nutritional supplements may also benefit her such as Instant Breakfast®, or a 360
calorie supplement (Ensure Plus®)
 Eating a bedtime snack each day.
 Limiting most of her liquids to between meals so that she don’t get too full to eat
solid food.

35.  Making mealtimes relaxing and pleasant. Stress at mealtime will limit the
appetite.
Ideas to control weight loss:
 Choose foods high in calories.
 Eat largest meal when most hungry during the day.
 Add additional butter or margarine to soups, gravies or sauces. It can also be
added to meats, rice, pasta, potatoes or other vegetables.
 Use whole milk or cream on cereals and in soups (instead of adding water to
cream soups, add same amount of milk).
 Cheese can be added to casseroles, potatoes, vegetables, eggs or sandwiches to
add calories and protein.
 Cream cheese and sour cream can be used as dips, spreads or as a topping to add
calories.
 Think of favorite foods and eat them often.
Source: http://www.nmhs.net/cancer_center
Signs and Symptoms (Side Effects)
Most side effects of chemotherapy can be predicted and can be prevented with
medications. Side effects occur because chemotherapy slows the growth of normal cells
as well as cancer cells. Examples of normal cells affected by chemotherapy include those
found in hair, the lining of the mouth and digestive system and the bloodstream. Side
effects that may occur as a result of the effect of chemotherapy on normal cells include:
 Hair loss
 Mouth sores
 Nausea and/or vomiting
 Diarrhea
 Fever
 Infections
 Fatigue
 Bleeding problems
 Low blood counts
 Skin/nail problems
 Constipation
Eating a light meal before your chemotherapy is sometimes helpful. Client’s
doctor will watch very closely for the occurrence of possible side effects. Emphasize to
the client that she should let her doctor and nurse know if any of these side effects occur.
Prescription medication, frequent exams and blood sampling will be used to prevent
and/or treat side effects.