Sunday, March 27, 2011

Cerebral Contusion is a Head injury that More serious than a concussion, a cerebral contusion is an ecchymosed of brain tissue that results from a severe blow to the head. When the head is abruptly brought to a stop against a solid object, the brain continues to move for an instant, hitting the inside the now stationary skull. The soft brain is easily contused and lacerated by the hard bony ridges at the base of the skull or by the tentorium cerebelli and falx cerebri. A contusion disrupts normal nerve functions in the bruised area and may cause loss of consciousness, hemorrhage, edema, and even death.
Causes For Cerebral Contusion
Cerebral contusion can happen to anyone, at any time. The most common causes of contusion include a blow to the head from a motor vehicle crash, fall or assault. People at higher risk are those who have difficulty walking and fall often, those who are active in high impact contact sports. It is also seen in child, spouse, and elder abuse. A cerebral contusion results from acceleration-deceleration or coup countercoup injuries. Contusions may correspond to the site of impact or develop opposite the impact (“coup” contusions- contre coup” contusions). Cerebral contusion that occur directly beneath the site of impact (coup) when the brain rebounds against the skull from the force of a blow (a beating with a blunt instrument, for example), when the force of the blow drives the brain against the opposite side of the skull (counter coup), or when the head is hurled forward and stopped abruptly (as in a motor vehicle accident when the driver’s head strikes the windshield). The brain continues moving, slaps against the skull (acceleration), and then rebounds (deceleration). A cerebral contusion can be distinguished from a cerebral infarct because, in the infarct, the superficial cortex is usually preserved, whereas in the contusion, it is the first to be damaged.

Complications for Cerebral Contusion
When injuries cause the brain to strike against bony prominences inside the skull (especially to the sphenoidal ridges), intracranial hemorrhage or hematoma can occur. The patient may also suffer tentorial herniation. Residual headache and vertigo may complicate recovery. Secondary effects, such as cerebral edema, may accompany serious contusions, resulting in increased intracranial pressure (ICP) and herniation.

Treatment for Cerebral Contusion
Contusions usually involve the surface of the brain, especially the crowns of gyri, and are more frequent in the orbital surfaces of the frontal lobes and the tips of the temporal lobes. Acute contusions show hemorrhagic necrosis and brain swelling. Gradually, macrophages remove necrotic brain tissue and blood. Eventually, the contusion evolves into a yellowish plaque characterized by loss and atrophy of brain tissue, glial scarring, hemosiderin deposition, and loss of axons in the underlying white matter. Immediate treatment may include establishing a patent airway and, if necessary, tracheotomy or endotracheal intubation. Treatment may also consist of careful administration of I.V. fluids I.V. mannitol to reduce ICP, and restricted fluid intake to decrease intracerebral edema. Dexamethasone may be given I.M. or I.V. for several days to control cerebral edema. An intracranial hemorrhage may require a craniotomy to locate and control bleeding and to aspirate blood. Epidural and subdural hematomas usually are drained by aspiration through burr holes in the skull. Increased ICP which can occur in hemorrhage, hematoma, and tentorial herniation may be controlled with mannitol I.V, steroids, or diuretics, but emergency surgery is usually required.

Nursing Assessment
The patient’s history reveals a severe traumatic impact to the head, commonly against a blunt surface such as a car dashboard. Signs and symptoms vary, depending on the location of the contusion and the extent of damage. A period of unconsciousness, possibly lasting 6 hours or more, may follow the trauma. An unconscious patient may appear pale and motionless, whereas a conscious patient may appear drowsy or easily disturbed by any form of stimulation, such as noise or light. A conscious patient may become agitated or violent. Assessment of an unconscious patient may reveal below-normal blood pressure and temperature. His pulse rate may be within normal levels but feeble, and his respirations may be shallow. In a conscious patient, temperature, pulse rate, and respiratory status vary, depending on his physical and emotional status.
  • Inspection may reveal severe scalp wounds, labored respirations and, possibly, involuntary evacuation of the bowels and bladder. Palpation may disclose less obvious head injuries such as hematoma. On palpation, the unconscious patient’s skin will feel cold. 
  • Neurologic findings may include hemiparesis, decorticate or decerebrate posturing, and unequal pupillary response. With effort, you may be able to temporarily rouse an unconscious patient. If you’re performing a neurologic examination after the acute stage of the injury, you may find that the patient has returned to a relatively alert state, perhaps with temporary aphasia, slight hemiparesis, or unilateral numbness. 

Diagnostic tests for Cerebral Contusion
Cerebral angiography outlines vasculature, and a Computed tomography (CT) scan CT scan MRI (magnetic resonance imaging)

Nursing diagnosis
Common Nursing diagnosis found in Nursing care plans for Cerebral Contusion

  • Acute pain 
  • Anxiety 
  • Decreased intracranial adaptive capacity 
  • Disturbed sensory perception: Kinesthetic, tactile 
  • Disturbed thought processes 
  • Impaired verbal communication 
  • Ineffective coping 
  • Risk for deficient fluid volume 
  • Risk for infection 
  • Risk for injury 
  • Risk for post trauma syndrome

Nursing Intervention and Rationale
Acute pain Related factors injuring agents (Cerebral Contusion)
Nursing Interventions: Pain Management Alleviation of pain or a reduction in pain to a level of comfort that is acceptable to the patient Analgesic Administration: Use of pharmacologic agents to reduce or eliminate pain Environmental Management Manipulation of the patient’s surroundings for promotion of optimal comfort

Nursing diagnosis Anxiety Related to Threat to or change in health status progressive debilitating disease, illness, interaction patterns, role function/status
Nursing Interventions:
Anxiety Reduction minimizing apprehension, dread, foreboding, or uneasiness related to an unidentified source or anticipated danger Provision of a modified environment for the patient who is experiencing a confusional state Calming Technique: Reducing anxiety in patient experiencing acute distress

Nursing diagnosis Ineffective cerebral tissue Perfusion Related to Interruption of blood flow by space-occupying lesions (hemorrhage, hematoma), cerebral edema
Nursing Interventions Neurologic Monitoring Cerebral Perfusion Promotion Collaborative oxygen, Prepare for surgical intervention, such as craniotomy or insertion of ventricular drain or ICP pressure monitor, if indicated, and transfer to higher level of care.

Nursing diagnosis Disturbed sensory perception: Kinesthetic, tactile Related to Altered sensory reception, transmission, and/or integration: Neurologic disease, trauma
Nursing Interventions
Communication Enhancement: Hearing/Vision Deficit: Assistance in accepting and learning alternative methods for living with diminished hearing/vision Environmental Management: Manipulation of the patient’s surroundings for therapeutic benefit Peripheral Sensation Management: Prevention or minimization of injury or discomfort in the patient with altered sensation

Nursing diagnosis Disturbed thought processes 

Nursing diagnosis Impaired verbal communication Related to decrease in circulation to brain, Cerebral Contusion 
Nursing Interventions: Communication Enhancement: Speech Deficit: Assistance in accepting and learning alternative methods for living with impaired speech Communication Enhancement: Hearing Deficit: Assistance in accepting and learning alternative methods for living with diminished hearing Active Listening: Attending closely to and attaching significance to a patient’s verbal and nonverbal messages 

Nursing diagnosis 
Ineffective coping Related to Impairment of nervous system cognitive, sensory, perceptual impairment, memory loss, Severe/chronic pain. 
Nursing Interventions: Coping Enhancement Assisting a patient to adapt to perceived stressors, changes, or threats that interfere with meeting life demands and roles Decision-Making Support Providing information and support for a person who is making a decision regarding healthcare Impulse Control Training Assisting the patient to mediate impulsive behavior through application of problem-solving strategies to social and interpersonal situations 

Nursing diagnosis 
Risk for deficient fluid volume 
Nursing Interventions: Fluid Monitoring: Collection and analysis of patient data to regulate fluid balance Hemodynamic Regulation: Optimization of heart rate, preload, afterload, and contractility Bleeding Precautions: Reduction of stimuli that may indicate bleeding or hemorrhage in at-risk patients 

Nursing diagnosis 
Risk for infection Risk factor inadequate primary defenses broken skin, traumatized tissue 
Nursing Interventions: Infection Protection Prevention and early detection of infection in a patient at risk Infection Control Minimizing the acquisition and transmission of infectious agents Surveillance Purposeful and ongoing acquisition, interpretation, and synthesis of patient data for clinical decision making 

Nursing diagnosis
Risk for injury 
Nursing Interventions: Safety Behavior: Personal: Individual or caregiver efforts to control behaviors that might cause physical injury Risk Actions to eliminate or reduce actual, personal, and modifiable health threats Safety Status: Physical Injury: Severity of injuries from accidents and trauma 

Nursing diagnosis 
Risk for post trauma syndrome Risk factors, serious injury or threat to self, criminal victimization. Tragic occurrence involving violent and/or multiple deaths; disasters; epidemics 
Nursing Interventions: Crisis Intervention Use of short-term counseling to help the patient cope with a crisis and resume a state of functioning comparable to or better than the pre-crisis state Coping Enhancement Assisting a patient to adapt to perceived stressors, changes, or threats that interfere with meeting life demands and roles Support System Enhancement Facilitation of support to patient by family, friends, and community 

Patient Teaching And Home Healthcare Guidance For Patient With Cerebral Contusion
Be sure the patient understands all medications, including the dosage, route, action, adverse effects, and the need for routine laboratory monitoring for convulsants. Teach the patient and caregiver the signs and symptoms that necessitate a return to the hospital. Teach the patient to recognize the symptoms and signs of post injury syndrome, which may last for several weeks. Explain that mild cognitive changes do not always resolve immediately. Provide the patient and significant others with information about the trauma clinic and the phone number of a clinical nurse specialist in case referrals are needed. Stress the importance of follow-up visits to the physician’s office. Patient with cerebral contusion may present with a variety of physical and cognitive disabilities, depending on the severity of the injury. Individuals may need treatment by physical, occupational, or speech therapists; neuropsychologists; vocational counselors; and/or social workers. Care for those experiencing moderate to severe Cerebral Contusion progresses along a continuum of care, beginning with acute hospital care and inpatient rehabilitation to sub acute and outpatient rehabilitation, as well as home- and community-based services. 
Patient teaching and home healthcare guidance for patient with Cerebral Contusion 

  • Tell the patient not to cough, sneeze, or blow his nose because these activities can increase ICP. 
  • Instruct the patient to observe for CSF drainage and to be alert for signs of infection. 
  • Teach the patient and his family how to observe for mental status changes and to return to the facility or to call the physician if such changes occur.

Friday, March 11, 2011

Although Thyroid cancer occurs in all age groups Incidence increases with age. The average age at time of diagnosis is 45. There appears to be an association between external radiation to the head and neck in infancy and childhood, and subsequent development of thyroid carcinoma. (Between 1949 and 1960, radiation therapy was commonly given to shrink enlarged tonsil and adenoid tissue, to treat acne, or to reduce an enlarged thymus.) People who have goiters have an increased risk for developing thyroid cancer. The incidence among such patients is 10–15 percent. A lack of iodine in the diet may lead to thyroid cancer. Because iodine is added to salt in the United States, thyroid cancer is rarely caused by iodine deficiencies in this country. Thyroid cancer may also have a genetic basis. Some researchers have found that an alteration in the RET gene may be transmitted from a parent to a child, causing medullary thyroid cancer. If several people in a family are diagnosed with thyroid cancer, other members may wish to be tested for a mutation of the RET gene. This syndrome, when present, is also called familial medullary thyroid cancer or Multiple Endocrine Neoplasia, type 2 (MEN 2). Individuals who have MEN 2 syndrome are also at risk for developing other types of cancer. 
Types characteristics of thyroid cancers 

  • Papillary adenocarcinoma (Most common and least aggressive, Asymptomatic nodule in a normal gland, Starts in childhood or early adult life, remains localized, Metastasizes along the lymphatics if untreated, More aggressive in the elderly, Growth is slow, and spread is confined to lymph nodes that surround thyroid area, Cure rate is excellent after removal of involved areas). Papillary carcinoma accounts for half of all thyroid cancers in adults; it’s most common in young adult females and metastasizes slowly. It’s the least virulent form of thyroid cancer. Follicular carcinoma is less common but more likely to recur and metastasize to the regional nodes and through blood vessels into the bones, liver, and lungs. 
  • Follicular adenocarcinoma ( Appears after 40 years of age, Encapsulated; feels elastic or rubbery on palpation, Spreads through the bloodstream to bone, liver, and lung, Prognosis is not as favorable as for papillary adenocarcinoma, Brief encouraging response may occur with irradiation, Progression of disease is rapid; high mortality ) 
  • Medullary (Appears after 50 years of age, Occurs as part of multiple endocrine neoplasia MEN), Hormone-producing tumor causing endocrine dysfunction symptoms, Metastasizes by lymphatics and bloodstream, Moderate survival rate, inheritable type of thyroid malignancy, which can be detected early by a radioimmunoassay for calcitonin ) 
  • Anaplastic (50% of anaplastic thyroid carcinomas occur in patients older than 60 years, Hard, irregular mass that grows quickly and spreads by direct invasion to adjacent tissues, May be painful and tender, Survival for patients with anaplastic cancer is usually less than 6 months, The most aggressive and lethal solid tumor found in humans, Least common of all thyroid cancers, Usually fatal within months of diagnosis) 
  • Thyroid lymphoma (Appears after age 40 years, May have history of goiter, hoarseness, Dyspnea, pain, and pressure, Good prognosis ) 

Complications For Thyroid Cancers
Untreated thyroid carcinoma can be fatal. Hemorrhage Hematoma formation Edema of the glottis Injury to the recurrent laryngeal nerve Hypothyroidism occurs in 5% of patients in first postoperative year; increases at rate of 2% to 3% per year. Hypoparathyroidism occurs in about 4% of patients and is usually mild and transient; requires calcium supplements I.V. and orally when more severe. 

Clinical Manifestations for Thyroid Cancers 
On palpation of the thyroid, there may be a firm, irregular, fixed, painless mass or nodule. The occurrence of signs and symptoms of hyperthyroidism is rare. 

Symptoms of Thyroid Cancer 
As with many other forms of cancer, most people in the early stages of thyroid cancer have no symptoms or signs of disease. When symptoms or signs occur, they may include the following: Hoarseness A lump near the Adam’s apple of the neck Swollen lymph nodes in the neck or nearby Dysphagia (difficulty swallowing) Pain in the neck or throat Medullary carcinoma of the thyroid secretes CALCITONIN and thus can cause symptoms due to the presence of this hormone, such as flushing, nausea, and diarrhea. In addition, medullary carcinoma of the thyroid is often inherited. Family members can be screened by measuring their calcitonin levels or by looking for abnormal chromosomes, such as RET. Anaplastic carcinoma typically presents in older men as a very hard mass in the neck. It is often incurable at the time of diagnosis, as it does not concentrate iodine, and thus radioactive iodine (RAI) therapy cannot be used. It is poorly responsive, if at all, to chemotherapy and external radiation therapy. 

Nursing . Assessment
Focused Nursing Assessment for Thyroid CancerExplore patient’s feelings and concerns regarding the diagnosis, treatment, and prognosis. The first indication of disease may be a painless nodule discovered incidentally or detected during physical examination.If the tumor grows large enough to destroy the thyroid gland. Patient’s history may include sensitivity to cold and mental apathy (hypothyroidism). If the tumor triggers excess thyroid hormone production, the patient may report sensitivity to heat, restlessness, and overactivity (hyperthyroidism). The patient may also complain of diarrhea, dysphagia, anorexia, irritability, and ear pain. When speaking with the patient, you may hear hoarseness and vocal stridor. On inspection, you may detect a disfiguring thyroid mass, especially if the patient is in the later stages of anaplastic thyroid cancer. (See Anaplastic thyroid cancer.) Palpation may disclose a hard nodule in an enlarged thyroid gland or palpable lymph nodes with thyroid enlargement. By auscultation, you may discover bruits if thyroid enlargement results from an increase in TSH, which increases thyroid vascularity. 

Diagnostic Evaluation 
A thyroid scan with 99mTc will detect a cold nodule with little uptake FNA biopsy Surgical exploration ultrasound MRI CT scans Thyroid scans Radioactive Iodine uptake studies Thyroid suppression tests 

Nursing Diagnosis 
Commong Nursing Diagnosis That Could Be Found In Patient With Thyroid Cancer: Fear/Anxiety [specify level] Acute/chronic Pain Risk for ineffective Airway Clearance Impaired verbal Communication Risk for Injury, [tetany, thyroid storm] Deficient Knowledge [Learning Need] regarding Condition, prognosis, treatment, self-care, and Discharge needs Nursing Care Plan for Thyroid Cancer. 

Nursing Intervention and Rationale Nursing Care Plan for Thyroid Cancer Nursing Diagnosis Fear/Anxiety Could be related to: 

  • Situational crisis cancer Thyroid Cancer 
  • Threat to, or change in, health, socioeconomic status, role functioning, interaction patterns 
  • Threat of death 
  • Separation from family hospitalization, treatments, diagnostic procedures, diagnosis of chronic/life-threatening condition 

Nursing Outcomes Evaluation Criteria, Client Will: 

  • Fear or Anxiety Self Control: Display appropriate range of feelings and lessened fear. Appear relaxed and report anxiety is reduced to a manageable level. Demonstrate use of effective coping mechanisms and active participation in treatment regimen. 

Nursing Interventions and rationale Nursing diagnosis Fear/Anxiety: 

  • Review client’s and significant other’s (SO’s) previous experience with cancer. Determine what the doctor has told client and what conclusion client has reached. Rationale Clarifies client’s perceptions; assists in identification of fear(s) and misconceptions based on diagnosis and experience with cancer. 
  • Ascertain client/SO(s) perception of what is occurring and how this affects life. Rationale Fear is a natural reaction to frightening events and how client views the event will determine how he or she will react 
  • Encourage client to share thoughts and feelings. Rationale Provides opportunity to examine realistic fears and misconceptions about diagnosis. 
  • Provide open environment in which client feels safe to discuss feelings or to refrain from talking. Rationale Helps client feel accepted in present condition without feeling judged and promotes sense of dignity and control. 
  • Be alert to signs of denial/depression. Indicates need for specific interventions to identify and deal with problems. Rationale Client may deny problems until unable to deal with situation. Depression may accompany problems associated with fear that interfere with daily activities 
  • Maintain frequent contact with client. Talk with and touch client, as appropriate. Rationale Provides assurance that the client is not alone or rejected; conveys respect for and acceptance of the person, fostering trust. 
  • Be aware of effects of isolation on client when required by immunosuppression or radiation implant. Limit use of isolation clothing, as possible. Rationale Sensory deprivation may result when sufficient stimulation is not available and may intensify feelings of anxiety, fear, and alienation. 
  • Assist client and SO in recognizing and clarifying fears to begin developing coping strategies for dealing with these fears. Rationale Coping skills are often stressed after diagnosis and during different phases of treatment. Support and counseling are often necessary to enable individual to recognize and deal with fear and to realize that control and coping strategies are available. 
  • Provide accurate, consistent information regarding diagnosis and prognosis. Avoid arguing about client’s perceptions of situation. Rationale Can reduce anxiety and enable client to make decisions and choices based on realities. 
  • Explain the recommended treatment, its purpose, and potential side effects. Help client prepare for treatments. Rationale The goal of cancer treatment is to destroy malignant cells while minimizing damage to normal ones. Treatment may include curative, preventive, or palliative surgery as well as chemotherapy, internal or external radiation, or newer, organ-specific treatments such as whole-body hyperthermia or biotherapy. Bone marrow or peripheral progenitor cell transplant may be recommended for some types of cancer. 
  • Note ineffective coping such as poor social interactions, helplessness, giving up everyday functions, and usual sources of gratification. Rationale Identifies individual problems and provides support for client and SO in using effective coping skills. 
  • Administer anti-anxiety medications, such as lorazepam (Ativan) or alprazolam (Xanax), as indicated. Rationale May be useful for brief periods of time to help client handle feelings of anxiety related to diagnosis or situation during periods of high stress, to assist client with diagnostic procedures, such as lying still during scan, and/or to minimize nausea. 
  • Refer to additional resources for counseling and support as needed. Rationale May be useful from time to time to assist client and SO in dealing with anxiety. 

Nursing Diagnosis Acute pain/Chronic Pain Related to: 

  • Disease process compression or destruction of nerve tissue, infiltration of nerves or their vascular supply, obstruction of a nerve pathway, inflammation, metastasis to bones. Side effects of various cancer therapy agents 

Nursing Outcomes Evaluation Criteria Client Will 

  • Report maximal pain relief or control with minimal interference with activities of daily living (ADLs). 
  • Follow prescribed pharmacological regimen. 
  • Demonstrate use of relaxation skills and diversional activities as indicated for individual situation.

Nursing Interventions and Rationale Nursing Diagnosis Acute/Chronic Pain 

  • Determine pain history, for example, location of pain, frequency, duration, and intensity using a rating scale (scale of 0–10), or verbal rating scale “no pain” to “excruciating pain”; and relief measures used. Believe client’s report. Rationale Information provides baseline data to evaluate need for, and effectiveness of, interventions. Pain of more than 6 months’ duration constitutes chronic pain, which may affect therapeutic choices. Recurrent episodes of acute pain can occur within chronic pain, requiring increased level of intervention. 
  • Evaluate painful effects of particular therapies, such as surgery, radiation, chemotherapy, or biotherapy. Provide information to client about what to expect. Rationale A wide range of discomforts are common such as incisional pain, burning skin, low back pain, mouth sores, or headaches, depending on the procedure or agent being used. Pain is also associated with invasive procedures to diagnose or treat cancer. 
  • Provide nonpharmacological comfort measures such as massage, repositioning, and back rub; as well as diversional activities, such as music, reading, and TV. Rationale Promotes relaxation and helps refocus attention. 
  • Place in semi-Fowler’s position and support head and neck in neutral position with sandbags or small pillows as required in immediate postoperative phase. Instruct client to use hands to support neck during movement and to avoid hyperextension of neck. Rationale Prevents hyperextension of the neck 
  • Encourage use of stress management skills and complementary therapies such as relaxation techniques, visualization, guided imagery, biofeedback, laughter, music, aromatherapy, and Therapeutic Touch. Rationale Enables client to participate actively in nondrug treatment of pain and enhances sense of control. Pain produces stress and, in conjunction with muscle tension and internal stressors, increases client’s focus on self, which in turn increases the level of pain. 
  • Provide cutaneous stimulation, such as heat and cold packs, or massage. Rationale May decrease inflammation, muscle spasms, reducing associated pain. 
  • Be aware of barriers to cancer pain management related to client, as well as the healthcare system. Rationale Clients may be reluctant to report pain for reasons such as fear that disease is worse; worry about unmanageable side effects of pain medications; belief that pain has meaning, such as “God wills it,” they should overcome it; or that pain is merited or deserved for some reason. Healthcare system problems include factors such as inadequate assessment of pain, concern about controlled substances or client addiction, inadequate reimbursement, and cost of treatment modalities. 
  • Evaluate pain relief at regular intervals. Adjust medication regimen as necessary. Inform client and SO of the expected therapeutic effects and discuss management of side effects. Rationale Goal is maximum pain control with minimum interference with ADLs. 
  • Develop individualized pain management plan with the client and physician. Provide written copy of plan to client, family and SO, and care providers. Rationale An organized plan beginning with the simplest dosage schedules and least invasive modalities improves chance for pain control. Particularly with chronic pain, client and SO must be active participant in pain management and all care providers need to be consistent. 
  • Refer to structured support group, psychiatric clinical nurse specialist, psychologist, or spiritual advisor for counseling, as indicated. Rationale May be necessary to reduce anxiety and enhance client’s coping skills, decreasing level of pain. Note: Hypnosis can heighten awareness and help to focus concentration tondecrease perception of pain. 

Nursing Diagnosis Risk for Ineffective Airway Clearance Related to 

  • Tracheal obstruction, swelling, bleeding, laryngeal spasms. 

Nursing Outcomes Evaluation Criteria Client Will 

  • Maintain patent airway, with aspiration prevented. 

Nursing Interventions and Rationale Nursing Diagnosis Risk for Ineffective Airway Clearance 

  • Monitor respiratory rate, depth, and work of breathing. Rationale Respirations may remain somewhat rapid because of hyperthyroid state, but development of respiratory distress is indicative of tracheal compression from edema or hemorrhage. 
  • Auscultate breath sounds, noting presence of rhonchi. Rationale Rhonchi may indicate airway obstruction and accumulation of copious thick secretions. 
  • Assess for Dyspnea, stridor, “crowing,” and cyanosis. Note quality of voice. Rationale Indicators of tracheal obstruction or laryngeal spasm, requiring prompt evaluation and intervention. 
  • Keep head of bed elevated 30 to 45 degrees. Caution client to avoid bending neck; support head with pillows in the immediate postoperative period. Rationale Enhances breathing and reduces likelihood of tension on surgical wound. 
  • Assist with repositioning, deep breathing exercises, and coughing, as indicated. Rationale Maintains clear airway and ventilation. Although “routine” coughing is not encouraged and may be painful, it may be necessary to clear secretions. 
  • Investigate reports of difficulty swallowing and drooling of oral secretions. Rationale May indicate edema and sequestered bleeding in tissues surrounding operative site. 
  • Keep tracheostomy tray at bedside. Rationale Compromised airway may create a life-threatening situation requiring emergency procedure. 
  • Provide steam inhalation, humidify room air. Rationale Reduces discomfort of sore throat and tissue edema and promotes expectoration of secretions. 
  • Assist with and prepare for procedures, such as: Tracheostomy Rationale although rare, tracheostomy may be necessary to obtain airway if obstructed by edema of glottis or hemorrhage. 

Nursing Diagnosis Impaired Verbal Communication Related to: 

  • Vocal cord injury, laryngeal nerve damage. Tissue edema; pain and discomfort 

Nursing Outcomes Evaluation Criteria Client Will 

  • Establish method of communication in which needs can be understood. 

Nursing Interventions and Rationale: 

  • Assess speech periodically and encourage voice rest. Rationale Hoarseness and sore throat may occur secondary to tissue edema or surgical damage to recurrent laryngeal nerve and may last several days. Permanent nerve damage can occur (rare) that causes paralysis of vocal cords and or compression of the trachea. 
  • Keep communication simple. Ask yes and no questions. Rationale Reduces demand for response; promotes voice rest. 
  • Provide alternative methods of communication as appropriate—slate board, letter and picture board. Place intravenous (IV) line to minimize interference with written communication. Rationale Facilitates expression of needs. 
  • Anticipate needs as much as possible. Visit client frequently. Rationale Reduces anxiety and client’s need to communicate. 
  • Post notice of client’s voice limitations at central station and answer call light promptly. Rationale Prevents client from straining voice to make needs known and summon assistance. 
  • Maintain quiet environment. Rationale Enhances ability to hear whispered communication and reduces necessity for client to raise and strain voice to be heard. 

Nursing Diagnosis Risk For Injury Related to: 

  • tetany, thyroid storm. Chemical imbalance, such as with hypocalcemia, increased release of thyroid hormones, excessive central nervous system (CNS). Stimulation 

Nursing Outcomes Evaluation Criteria Client Will 

  • Demonstrate absence of injury with complications minimized or controlled. 

Nursing Interventions And Rationale 

  • Monitor vital signs, noting elevated temperature, tachycardia (140 to 200 beats/minute), dysrhythmias, respiratory distress, and cyanosis—developing pulmonary edema or heart failure (HF). Rationale : Manipulation of gland during subtotal thyroidectomy may result in increased hormone release, causing thyroid storm. 
  • Evaluate reflexes periodically. Observe for neuromuscular irritability—twitching, numbness, paresthesias, positive Chvostek’s and Trousseau’s signs, and seizure activity. Rationale : Hypocalcemia with tetany (usually transient) may occur 1 to 7 days postoperatively and indicates hypoparathyroidism, which can occur because of inadvertent trauma to and partial to total removal of parathyroid gland(s) during surgery. 
  • Keep side rails raised and padded, bed in low position, and airway at bedside. Avoid use of restraints. Rationale Reduces potential for injury if seizures occur. (Refer to CP: Seizure Disorders, ND: risk for Trauma/Suffocation.) 
  • Monitor serum calcium levels. Rationale : Clients with levels less than 7.5 mg/100 mL generally require replacement therapy. 
  • Administer medications, as indicated, for example: IV calcium (gluconate or chloride) Phosphate-binding agents, Sedativesm Anticonvulsants Rationale : Corrects deficiency, which is usually temporary but may be permanent. Note: Use with caution in clients taking digoxin because calcium increases cardiac sensitivity to digoxin, potentiating risk of toxicity. Helpful in lowering elevated phosphorus levels associated with hypocalcemia. Promotes rest, reducing exogenous stimulation. Controls seizure activity associated with thyroid storm until corrective therapy is successful. 

Nursing Diagnosis Deficient Knowledge Regarding Condition, Prognosis, Treatment, Self-Care, And Discharge Needs Related to

  • Lack of exposure and recall; misinterpretation, Unfamiliarity with information resources 

Nursing Outcomes Evaluation Criteria Client Will 

  • Verbalize understanding of surgical procedure and prognosis and potential complications. 
  • Verbalize understanding of therapeutic needs.
  •  Participate in treatment regimen. 
  • Initiate necessary lifestyle changes. 

Nursing Interventions and Rationale 

  • Review surgical procedure and future expectations. Rationale Provides knowledge base from which client can make informed decisions. 
  • Discuss need for well-balanced, nutritious diet and, when appropriate, inclusion of iodized salt. Rationale Promotes healing and helps client regain and maintain appropriate weight. Use of iodized salt is often sufficient to meet iodine needs unless salt is restricted for other healthcare problems, such as with HF. 
  • Identify foods high in calcium, such as dairy products, and vitamin D, such as fortified dairy products, egg yolks, and liver. Rationale Maximizes supply and absorption of calcium if parathyroid function is impaired. 
  • Encourage progressive general exercise program. Rationale In clients with subtotal thyroidectomy, exercise can stimulate the thyroid gland and production of hormones, facilitating recovery of general well-being. 
  • Review postoperative exercises to be instituted after incision heals flexion, extension, rotation, and lateral movement of head and neck. Rationale Regular range-of-motion (ROM) exercises strengthen neck muscles and enhance circulation and healing process. 
  • Review importance of rest and relaxation, avoiding stressful situations and emotional outbursts. Rationale Effects of hyperthyroidism usually subside completely, but it takes some time for the body to recover. 
  • Instruct in incision care cleansing and dressing application. Rationale Enables client to provide competent self-care. Note: Neck incisions heal rapidly and are watertight within 24 to 36 hours. 
  • Recommend the use of loose-fitting scarves to cover scar, avoiding the use of jewelry. Rationale Covers the incision without aggravating healing or precipitating infections of suture line. 
  • Discuss possibility of change in voice. Rationale Normal surgical area swelling and vocal cord dysfunction can cause changes in pitch and quality of voice, which may be temporary or permanent. 
  • Review drug therapy and the necessity of continuing even when feeling well. Rationale If thyroid hormone replacement is needed because of surgical removal of gland, client needs to understand rationale for replacement therapy and consequences of failure to routinely take medication. 
  • Identify signs and symptoms requiring medical evaluation: fever, chills, continued and purulent wound drainage, erythema, gaps in wound edges, sudden weight loss, intolerance to heat, nausea and vomiting, diarrhea, insomnia, weight gain, fatigue, intolerance to cold, constipation, and drowsiness. Rationale Early recognition of developing complications, such as infection, hyperthyroidism, or hypothyroidism, may prevent progression to life-threatening situation. 
  • Stress necessity of continued medical follow-up. Rationale Provides opportunity for evaluating effectiveness of therapy and prevention of complications. 

Patient Teaching Thyroid Cancer Patient Teaching discharge and Home Health Guidance for Patient with Thyroid Cancer. To maintain a euthyroid state, teach family and patient sign and symptoms of hypothyroidism for early detection of problems: weakness, fatigue, cold intolerance, weight gain, facial puffiness, periorbital edema, bradycardia, and hypothermia. Be sure the patient understands all medications, including the dosage, route, action, and adverse effects. Explain that the patient needs routine follow-up laboratory tests to check TSH and thyroxine (T4) levels. Be sure the patient knows when the first postoperative physician’s visit is scheduled. Explain any wound care and that the patient should expect to be hoarse for a week or so after the surgical procedure. 
Patient Teaching discharge and Home Health Guidance for Patient with Thyroid Cancer: 

  • Preoperatively, advise the patient to expect temporary voice loss or hoarseness for several days after surgery. Also, explain the operation and postoperative procedures and positioning. 
  • Instruct the patient on thyroid hormone replacement and follow-up blood tests. 
  • Stress the need for periodic evaluation for recurrence of malignancy. 
  • Supply additional information or suggest community resources dealing with cancer prevention and treatment. 
  • Assist patient in identifying sources of information to structured support group, psychiatric clinical nurse specialist, psychologist, or spiritual advisor for counseling, May be necessary to reduce anxiety and enhance client’s coping skills, decreasing level of pain. Note: Hypnosis can heighten awareness and help to focus concentration tondecrease perception of pain 
  • Assist patient in identifying sources of information and support available in the community Refer the patient to resource and support services, such as the social service department, home health care agencies, hospices, and the American Cancer Society 
  • Before discharge, ensure that the patient knows the date and time of his next appointment. Answer his questions about his treatment and home care. Be sure he understands the purpose of his medications, dosage, administration times, and possible adverse effects

Tuesday, February 15, 2011

Cancer of the larynx is a malignant tumor in the larynx (voice box). It is potentially curable if detected early. It represents less than 1% of all cancers and occurs about four times more frequently in men than in women, and most commonly in persons 50 to 70 years of age. Squamous cell carcinoma constitutes about 95% of laryngeal cancers. Rare laryngeal cancer forms adenocarcinoma and sarcoma account for the rest. An intrinsic tumor is on the true vocal cords and tends not to spread because underlying connective tissues lack lymph nodes. An extrinsic tumor is on some other part of the larynx and tends to spread easily. Laryngeal 
Cancer is classified by its location: 
Supraglottis (false vocal cords) Glottis (true vocal cords) Sub glottis (rare downward extension from vocal cords). 

Pathophysiology and Etiology of Laryngeal Cancer 
Occurs predominantly in men older than age 60. Most patients have a history of smoking; those with Supraglottis laryngeal cancer frequently have a history of smoking and a high alcohol intake. Other risk factors include vocal straining, chronic laryngitis, industrial exposure, nutritional deficiency, and family predisposition. About two-thirds of carcinomas of the larynx arise in the glottis, almost one-third arise in the Supraglottis region, and about 3% arise in the subglottic region of the larynx. When limited to the vocal cords (intrinsic), spread is slow because of lessened blood supply. When cancer involves the epiglottis (extrinsic), cancer spreads more rapidly because of abundant supply of blood and lymph and soon involves the lymph nodes of the neck. A malignant growth may occur in three different areas of the larynx: the glottis area (vocal cords), Supraglottis area (area above the glottis or vocal cords, including epiglottis and false cords), and sub glottis (area below the glottis or vocal cords to the cricoid). Two thirds of laryngeal cancers are in the glottis area. Supraglottis cancers account for approximately one third of the cases, subglottic tumors for less than 1%. Glottic tumors seldom spread if found early because of the limited lymph vessels found in the vocal. 

Causes for Laryngeal Cancer 
The cause of laryngeal cancer is unknown. Major risk factors include smoking and alcoholism. Minor risk factors include chronic inhalation of noxious fumes and familial disposition. An initial assessment includes a complete history and physical examination of the head and neck. This will include assessment of risk factors, family history, and any underlying medical conditions. Varied assessment findings in laryngeal cancer depend on the tumor’s location and its stage. With stage I disease, the patient may complain of local throat irritation or hoarseness that lasts about 2 weeks. In stages II and III, he usually reports hoarseness. He may also have a sore throat, and his voice volume may be reduced to a whisper. In stage IV, he typically reports pain radiating to his ear, dysphagia, and dyspnea. In advanced (stage IV) disease, palpation may detect a neck mass or enlarged cervical lymph nodes. 

Diagnostic tests 
The usual workup includes laryngoscopy, xeroradiography, biopsy, laryngeal tomography and computed tomography scans, and laryngography to visualize and define the tumor and its borders. Chest X-ray findings can help detect metastases. An indirect laryngoscopy, using a flexible endoscope, is initially performed in the otolaryngologist’s office to visually evaluate the pharynx, larynx, and possible tumor. Mobility of the vocal cords is assessed; if normal movement is limited, the growth may affect muscle, other tissue, and even the airway. The lymph nodes of the neck and the thyroid gland are palpated to determine spread of the malignancy. If a tumor of the larynx is suspected on an initial examination, a direct laryngoscopic examination is scheduled. This examination is done under local or general anesthesia and allows evaluation of all areas of the larynx. Samples of the suspicious tissue are obtained for histologic evaluation. The tumor may involve any of the three areas of the larynx and may vary in appearance. Computed tomography and magnetic resonance imaging (MRI) are used to assess regional adenopathy and soft tissue and to help stage and determine the extent of a tumor. MRI is also helpful in post-treatment follow-up in order to detect a recurrence. Positron emission tomography (PET scan) may also be used to detect recurrence of a laryngeal tumor after treatment. 

Treatment Management For Laryngeal Cancer Depends on sites and stages of cancer. Early malignancy may be removed endoscopically. Early lesions may respond to laser surgery or radiation therapy; advanced lesions to laser surgery, radiation therapy, and chemotherapy. Treatment aims to eliminate cancer and preserve speech. If speech preservation isn’t possible, speech rehabilitation may include esophageal speech or prosthetic devices. Other surgical procedures vary with tumor size and include cordectomy, partial or total laryngectomy, Supraglottic laryngectomy, and total laryngectomy with laryngoplasty. 

Risk Factors for Laryngeal Cancer Carcinogens: Tobacco (smoke, smokeless), Combined effects of alcohol and tobacco, Asbestos, Second-hand smoke, Paint fumes, Wood dust, Cement dust, Chemicals, Tar products, Mustard gas, Leather and metals. Other Factors: Straining the voice, chronic laryngitis, Nutritional deficiencies (riboflavin), History of alcohol abuse Familial predisposition, Age (higher incidence after 60 years of age), Gender (more common in men), Race (more prevalent in African Americans), weakened immune system. 

Clinical Manifestations for Laryngeal Cancer Varied assessment findings in laryngeal cancer Depend on tumor location and its stage; sequence in appearance related to pattern and extent of tumor growth. Supraglottic Cancer: Tickling sensation in throat Dryness and fullness (lump) in throat Painful swallowing (odynophagia) associated with invasion of extra laryngeal musculature Coughing on swallowing Pain radiating to ear (late symptom) Glottic Cancer (Cancer of the Vocal Cord): Most common cancer of the larynx Hoarseness or voice change Aphonia (loss of voice) Dyspnea Pain (in later stages) Subglottic Cancer (Uncommon): Coughing Short periods of difficulty in breathing Hemoptysis; fetid odor, which results from ulceration and disintegration of tumor With stage I disease Hoarseness of more than 2 weeks’ duration is noted early in the patient with cancer in the glottic area because the tumor impedes the action of the vocal cords during speech. The voice may sound harsh, raspy, and lower in pitch. Affected voice sounds are not early signs of subglottic or supraglottic cancer. In stages II and III, he usually reports hoarseness. He may also have a sore throat that does not go away, and his voice volume may be reduced to a whisper and pain and burning in the throat, especially when consuming hot liquids or citrus juices. A lump may be felt in the neck. Later symptoms In stage IV typically reports pain radiating to his ear dysphagia, dyspnea (difficulty breathing), unilateral nasal obstruction or discharge, persistent hoarseness, persistent ulceration, and foul breath. Cervical lymph adenopathy, unplanned weight loss, a general debilitated state, and pain radiating to the ear may occur with metastasis. palpation may detect a neck mass or enlarged cervical lymph nodes. 

Treatment Management For Laryngeal Cancer 
Radiation therapy: Singly or in combination with surgery. Complications of radiation including airway obstruction, edema of larynx, soft tissue and cartilage necrosis, chondritis, pain, and loss of taste (xerostomia). Surgery therapy: Carbon dioxide laser for early-stage disease. Partial laryngectomy removal of small lesion on true cord, along with a substantial margin of healthy tissue. Supraglottic laryngectomy removal of hyoid bone, epiglottis, and false vocal cords, tracheostomy may be done to maintain adequate airway, radical neck dissection may be done. Hemilaryngectomy removal of one true vocal cord, false cord, one half of thyroid cartilage, arytenoid cartilage. Total laryngectomy removal of entire larynx (epiglottis, false or true cords, cricoid cartilage, hyoid bone; two or three tracheal rings are usually removed when there is extrinsic cancer of the larynx [extension beyond the vocal cords]). A radical neck dissection may also be done because of metastasis to cervical lymph nodes. Total laryngectomy with laryngoplasty voice rehabilitation may be attempted through the Asai operation: A dermal tube is made from the upper end of the trachea into the hypo pharynx. The tracheostomy opening is closed off with a finger. The patient expires air up the dermal tube into the pharyngeal cavity. The sound produced is transformed into almost normal speech. 

Complications of Surgery therapy 
  • Salivary fistula may develop after any surgical procedure that involves entering the pharynx or esophagus. (Monitor for saliva collecting beneath the skin flaps or leaking through suture line or drain site. Management NG tube feeding, meticulous local wound care with frequent dressing changes, promotion of drainage) 
  • Hemorrhage (carotid artery rupture) or hematoma formation. A major postoperative complication (e.g. skin necrosis or salivary fistula) usually precedes carotid artery rupture. Management immediate wound exploration in operating room. 
  • Stomas stenosis. 
  • Aspiration. 
  • Long-term complications: Chest infections (from repeated aspiration), Recurrence of cancer in stoma 

Nursing Assessment for Laryngeal Cancer The nurse assesses the patient for the following symptoms: hoarseness, sore throat, dyspnea, dysphagia, or pain and burning in the throat. The neck is palpated for swelling. If treatment includes surgery, the nurse must know the nature of the surgery to plan appropriate care. If the patient is expected to have no voice, a preoperative evaluation by the speech therapist is indicated. The patient’s ability to hear, see, read, and write is assessed. Visual impairment and functional illiteracy may create additional problems with communication and require creative approaches to ensure that the patient is able to communicate any needs. In addition, the nurse determines the psychological readiness of the patient and family. The idea of cancer is terrifying to most people. Fear is compounded by the possibility of permanently losing voice and, in some cases, of having some degree of disfigurement. The nurse evaluates the patient’s and family’s coping methods to support them effectively both preoperatively and postoperatively.

Nursing Diagnosis
Common Nursing Diagnosis found in patient with Laryngeal Cancer Ineffective airway clearance Impaired verbal communication Impaired skin/tissue integrity Impaired oral mucous membrane Acute pain Imbalanced nutrition: less than body requirements Disturbed body image/ineffective role performance deficient knowledge [learning need] regarding prognosis, treatment, self-care, and discharge needs Impaired swallowing Risk for infection

Nursing interventions
Ineffective Airway Clearance May be related to: 

  • Partial or total removal of the glottis, altering ability to breathe, cough, and swallow 
  • Temporary or permanent change to neck breathing dependent on patent stoma 
  • Edema formation surgical manipulation and lymphatic accumulation 
  • Copious and thick secretions 

Nursing Outcomes Evaluation Criteria, Client Will:

  • Respiratory Status: Airway Patency Maintain patent airway with breath sounds clear or clearing. 
  • Clear secretions and be free of aspiration. 

Nursing Intervention and Rationale Nursing Diagnosis Ineffective Airway Clearance:

  • Monitor vital sign respiratory rate and depth note ease of breathing. Auscultate breath sounds. Investigate restlessness, Dyspnea, and development of cyanosis. Rationale Changes in respirations, use of accessory muscles, and presence of crackles or wheezes suggest retention of secretions. Airway obstruction can lead to ineffective breathing patterns even partial Airway obstruction and impaired gas exchange, resulting in complications, such as pneumonia and respiratory arrest. 
  • Elevate head of bed 30 to 45 degrees. Rationale Facilitates drainage of secretions, work of breathing, and lung expansion. 
  • Encourage swallowing, if client is able. Rationale reducing risk of aspiration with Prevents pooling of oral secretions 
  • Encourage and teach effective coughing and deep breathing. Rationale Mobilizes secretions to clear airway and helps prevent respiratory complications. 
  • Suction laryngectomy and tracheostomy tube and oral and nasal cavities. Note amount, color, and consistency of secretions. Rationale Changes in character of secretions may indicate developing problems, such as dehydration and infection, and need for further evaluation and treatment. Prevents secretions from obstructing airway, especially when swallowing ability is impaired. 
  • Teach and encourage client to begin self suction procedures as soon as possible. Educate client in “clean” techniques. Rationale Reduces anxiety associated with difficulty in breathing or inability to handle secretions when alone. 
  • Maintain proper position of laryngectomy or tracheostomy tube. Check and adjust ties as indicated. Rationale As edema develops or subsides, tube can be displaced, compromising airway. Ties should be snug but not constrictive to surrounding tissue or major blood vessels. 
  • Observe tissues surrounding tube for bleeding. Change client’s position to check for pooling of blood behind neck or on posterior dressings. Rationale bleeding or sudden eruption of uncontrolled hemorrhage presents a sudden and real possibility of airway obstruction and suffocation. 
  • Provide supplemental humidification Rationale: Normal physiological on nasal passages means of filtering and humidifying air are bypassed. Supplemental humidity decreases mucous crusting and facilitates coughing or suctioning of secretions through stoma. 
  • Resume oral intake with caution Rationale Changes in muscle mass and strength and nerve innervations increase likelihood of aspiration. 
  • Monitor serial ABGs or pulse oximetry and chest x-ray. Rationale Pooling of secretions or presence of atelectasis may lead to pneumonia, requiring more aggressive therapeutic measures. 

Nursing Diagnosis Impaired Verbal Communication related to: 

  • Anatomical deficit removal of vocal cords 
  • Physical barrier tracheostomy tube 
  • Required voice rest 

Nursing Outcomes Evaluation Criteria Client Will:

  • Communication Enhancement: Speech Deficit Independent 
  • Communicate needs in an effective manner. 
  • Identify and plan for appropriate alternative speech methods after healing. Nursing Intervention and Rationale 

Nursing Diagnosis Impaired Verbal Communication:

  • Review preoperative instructions and discussion of why speech and breathing are altered, Rationale Reinforces teaching at a time when fear of surviving surgery is past. 
  • Determine whether client has other communication impairments, such as hearing, vision, and literacy. Rationale Presence of other problems influences plan for alternative communication. 
  • Provide immediate and continual means to summon nurse Prearrange signals for obtaining immediate help Rationale Client needs assurance that nurse is vigilant and will respond to summons. May decrease client’s anxiety about inability to speak. 
  • Allow sufficient time for communication. Rationale Loss of speech and stress of alternative communication can cause frustration and block expression, especially when caregivers seem “too busy” or preoccupied. 
  • Encourage ongoing communication with “outside world,” such as newspapers, television, radio, calendar, and clock. Rationale Maintains contact with “normal lifestyle” and continued communication through other avenues. 
  • Caution client not to use voice until physician gives permission. Rationale Promotes healing of vocal cord and limits potential for permanent cord dysfunction. 
  • Consult or refer with appropriate healthcare team members, therapists, speech pathologist, and social services. Refer to hospital-based rehabilitation, and community resources, such as Lost Chord or New Voice Club, International Association of Laryngectomees, and American Cancer Society. Rationale Ability to use alternative voice and speech methods, such as electrolarynx, TEP, voice prosthesis, and esophageal speech. Rehabilitation time may be lengthy and require a number of agencies and resources to facilitate or support learning process. 

Nursing diagnosis Impaired Skin/Tissue Integrity related to: 

  • Surgical removal of tissues and grafting 
  • Radiation or chemotherapeutic agents 
  • Altered circulation or reduced blood supply 
  • Compromised nutritional status 
  • Edema formation 
  • Pooling or continuous drainage of secretions oral, lymph, or chyle 

Nursing Outcomes Evaluation Criteria Client Will:

  • Wound Healing: Primary Intention 
  • Display timely wound healing without complications. 
  • Demonstrate techniques to promote healing and prevent complications. 

Nursing Intervention and Rationale Nursing Diagnosis Impaired Verbal Communication:

  • Assess skin color, temperature, and capillary refill in operative and skin graft areas. Rationale Cyanosis and slow refill may indicate venous congestion, which can lead to tissue ischemia and necrosis. 
  • Protect skin flaps and suture lines from tension or pressure. Provide pillow or rolls and instruct client to support head and neck during activity. Rationale Pressure from tubing and tracheostomy tapes or tension on suture lines can alter circulation and cause tissue injury. 
  • Monitor bloody drainage from surgical sites, suture lines, and drains Rationale Bloody drainage usually declines steadily after first 24 hours. Steady oozing or frank bleeding indicates problem requiring medical attention. 
  • Note and report any milky-appearing drainage. Rationale Milky drainage may indicate thoracic lymph duct leakage, which can result in depletion of body fluids and electrolytes. Such a leak may heal spontaneously or require surgical closure. 
  • Change dressings, as indicated. Rationale Damp dressings increase risk of tissue damage and infection. 
  • Cleanse thoroughly around stoma and neck tubes (if in place), avoiding soap or alcohol. Show client how to do self-care of stoma and tube with clean water and peroxide, using soft, lint-free cloth, not tissue or cotton. Rationale Keeping area clean promotes healing and comfort. Soap and other drying agents can lead to stomal irritation and possible inflammation. Materials other than cloth may leave fibers in stoma that can irritate or be inhaled into lungs. 
  • Monitor all sites for signs of wound infection, such as unusual redness; increasing edema, pain, exudates; and temperature elevation. Rationale Impedes healing, which may already be slow because of changes induced by cancer, cancer therapies, or malnutrition. 
  • Administer oral, IV, and topical antibiotics, as indicated. Rationale Prevents or controls infection. 

Nursing Diagnosis Impaired Oral Mucous Membrane related to 

  • Dehydration or absence of oral intake, decreased saliva production secondary to radiation or surgical procedure 
  • Poor or inadequate oral hygiene 
  • Pathological condition oral cancer, mechanical trauma oral surgery 
  • Difficulty swallowing and pooling of secretions and drooling 
  • Nutritional deficits 

Nursing Outcomes and Evaluation Criteria Client Will:

  • Tissue Integrity: Skin and Mucous Membranes 
  • Report or demonstrate a decrease in symptoms. 
  • Identify specific interventions to promote healthy oral mucosa. 
  • Demonstrate techniques to restore and maintain mucosal integrity. 
  • Oral Health Restoration 

Nursing Intervention and Rationale Nursing Diagnosis Impaired Oral Mucous Membrane:

  • Inspect oral cavity, Tongue, Lips Teeth and gums and Mucous membranes note changes in: Saliva Rationale Surgery or Damage to salivary glands Tongue, Lips Teeth and gums and Mucous membranes may decrease production of saliva, resulting in dry mouth. Pooling and drooling of saliva may occur because of compromised swallowing capability or pain in throat and mouth. 
  • Suction oral cavity frequently. Have client perform self-suctioning when possible or use gauze wick to drain secretions. Rationale Saliva contains digestive enzymes that may be erosive to exposed tissues. 
  • Show client how to brush inside of mouth, palate, tongue, and teeth. Rationale Frequent oral care reduces bacteria and risk of infection and promotes tissue healing and comfort. 
  • Apply lubrication to lips; provide oral irrigations as indicated. Rationale Counteracts drying effects of therapeutic measures and negates erosive nature of secretions. 
  • Avoid alcohol based mouthwashes. Rationale: Alcohol can be drying and irritating. 

Nursing Diagnosis Acute Pain related to: 

  • Surgical incisions 
  • Tissue swelling 
  • Presence of nasogastric or orogastric feeding tube 

Nursing Outcomes and Evaluation Criteria Client Will:

  • Report pain is relieved or controlled. 
  • Demonstrate relief of pain and discomfort by reduced tension and relaxed manner. Nursing Intervention and Rationale 

Nursing Diagnosis Acute Pain:

  • Evaluate pain level frequently. Rationale : Pain is a major concern for clients undergoing laryngectomy and it is believed as many as 32% still suffer severe distress, with the administered dosing less than needed to obtain optimal pain relief 
  • Investigate changes in characteristics of pain. Check mouth and throat suture lines for fresh trauma. Rationale May reflect developing complications requiring further evaluation or intervention. 
  • Provide comfort measures, such as back rub and position change, and Diversional activities, such as television, visiting, and reading. Rationale Promotes relaxation and helps client refocus attention on something beside pain. 
  • Schedule care activities to balance with adequate periods of sleep or rest. Rationale Prevents fatigue or exhaustion and may enhance coping with stress or discomfort. 
  • Administer analgesics such as on a scheduled basis or via patient-controlled analgesia; adjust dosages according to pain level per protocols. Rationale Degree of pain is related to extent and psychological impact of surgery as well as general body condition. 

Patient Teaching Discharge and Home Healthcare Guidelines
Patient Teaching Discharge and Home Healthcare Guidelines for Patient with Laryngeal Cancer. Teach the patient signs and symptoms of potential complications and the appropriate actions to be taken. Complications include infection (wound drainage, poor wound healing, fever, achiness, chills), airway obstruction and tracheostomy stenosis (noisy respirations, difficulty breathing, restlessness, confusion, increased respiratory rate), vocal straining; fistula formation (redness, swelling, secretions along a suture line), and ruptured carotid artery (bleeding, hypotension).Teach the patient the name, purpose, dosage, schedule, common side effects, and importance of taking all medications.
Teach the patient the appropriate devices and techniques to ensure a patent airway and prevent complications. Explore methods of communication that work effectively. Encourage the patient to wear a Medic Alert bracelet or necklace, which identifies her or him as a mouth breather. Provide the patient with a list of referrals and support groups, such as visiting nurses, American Cancer Society, American Speech-Learning-Hearing Association, International Association of Laryngectomees, and the Lost Cord Club

  • Before partial or total laryngectomy, instruct the patient in good oral hygiene practices. If appropriate, instruct a male patient to shave off his beard to facilitate postoperative care. 
  • Explain postoperative procedures, such as suctioning, NG tube feeding, and laryngectomy tube care. Carefully discuss the effects of these procedures (breathing through the neck and speech alteration, for example). 
  • After surgery Teach and encourage client to begin self suction procedures as soon as possible. Educate client in “clean” techniques. To Reduces anxiety associated with difficulty in breathing or inability to handle secretions when alone. 
  • Also, prepare the patient for other functional losses. Forewarn him that he won’t be able to smell aromas, blow his nose, whistle, gargle, sip, or suck on a straw. 
  • Reassure the patient that speech rehabilitation measures (including laryngeal speech, esophageal speech, an artificial larynx, and various mechanical devices) may help him communicate again. 
  • Encourage the patient to take advantage of services and information offered by the American Speech-Language-Hearing Association, the International Association of Laryngectomees, the American Cancer Society, or the local chapter of the Lost Chord Club.

Monday, January 17, 2011

Lung Cancer
Lung cancer is the uncontrolled growth of abnormal cells, which may occur in the lining of the trachea, bronchi, bronchioles, or alveoli. Ninety five percent of lung cancers are bronchogenic (arise from the epithelial lining of the bronchial tree).
Cause for Lung Cancers
Carcinogenesis, Initiation by a carcinogen (cancer-causing agent), for example, cigarette smoke, asbestos, or coal dust. Promotion by a secondary factor, for example, number of years smoking or number of cigarettes smoked. Progression, that is, the growth of pre-malignant cells and their ability to metastasize.
Lifestyle risk factors: Smoking, most common risk factor: 85% of people are or were former smokers. Others risk factor is Environmental tobacco smoke (secondhand smoke).About 3,400 lung cancer deaths in nonsmoking adults. Nonsmokers chronically exposed to secondhand smoke may have as much as a 24% increased risk for developing lung cancer.
Occupational risks: Radon, Asbestos fibers e.g. insulation and shipbuilding (7 times increased risk of death in asbestos workers & Asbestos exposure combined with cigarette smoking act synergistically to produce an increased risk of lung cancer), Arsenic (copper refining and pesticides), Beryllium (airline industry and electronics), Metals (nickel or copper), Chromium, Cadmium, Coal tar (mining), Mustard gas, Air pollution: diesel exhaust, Radiation, Tuberculosis.
Biological risks Sex/age: Males have a greater risk of lung cancer than do females, although incidence rate is declining significantly in men, from high of 102 per 100,000 in 1984 to 77.8 per 100,000 in 2002. Lung cancer incidence doubled in females from 1975 to 2000 and now has stabilized. Increased risk is associated with increasing age. 70% of all lung cancers diagnosed in individuals over the age of 65 and the number of cases diagnosed at 50 or earlier is increasing.
Family history: Lung cancer in one parent increases their children’s risk of the diagnosis of lung cancer before age 50.
Genetic predisposition: Genetic susceptibility is a contributing factor in those that develop lung cancer at a younger age. A single gene for lung cancer has not been identified. Abnormalities of p53 gene, a tumor-suppressor gene, have been suggested to be mutated in many people with lung cancer. EGFL6 gene identified as potential tumor marker.
Race: African Americans, native Hawaiians, and non-Hispanic whites have greater risk of lung cancer. Black men between the age of 35 and 64 years of age have twice the risk compared to non-Hispanic Whites.
Chronic inflammation, chronic obstructive pulmonary disease (COPD), and pulmonary fibrosis: Tuberculosis: Scarring of healthy lung tissue may lead to lung cancer development. Pulmonary fibrosis: Silica is the probable lung carcinogen. COPD: Airflow limitation results in a 6.44 times greater risk for lung cancer compared with the risk associated with absence of ventilator impairment. 

To categorize lung cancers visible Pathologic features on light microscopy, are used. Lung cancers are divided into two major groups, Small Cell Lung Cancer and Non–Small Cell Lung Cancer
Non-Small Cell Lung Cancer

  • Squamous cell (epidermoid forms in the lining of the bronchial tubes). Most common type of lung cancer in men. Decreasing incidence in last two decades. Typically develops in segmental bronchi, causing bronchial obstruction and regional lymph node involvement. Symptoms are related to obstruction : nonproductive cough, pneumonia, atelectasis, that is, a collapsed lung, chest pain is a late symptom associated with bulky tumor, Pancoast Tumor, or pulmonary sulcus tumor, begins in the upper portion of the lung and commonly spreads to the ribs and spine causing classic shoulder pain that radiates down the ulnar nerve distribution. Treatment: surgical resection is preferred before the development of metastatic disease, chemotherapy and radiation therapy to decrease the incidence of recurrence. 
  • Adenocarcinoma. Most common form in Unites States, Increasing incidence in females. Occurs in non smokers. adenocarcinoma develops in the periphery of the lungs and frequently metastasizes to brain, bone, and liver. Symptoms: no symptoms with small peripheral lesions, Identifi ed by routine chest radiograph/CT scan. Treatment: surgical resection and chemotherapy and radiation therapy to decrease the incidence of recurrence. 
  • Bronchioalveolar (BAC). Form near the lung’s air sacs. BAC may have abnormal gene in their tumor cells. Targeted chemotherapy treatment appears to be effective. 
  • Large cell. Large cell: 10% of all lung cancer cases. Bulky peripheral tumor. Metastasizing to brain, bone, adrenal glands, or liver. Symptoms related to obstruction or metastatic spread pneumonitis and pleural effusions. Treatment: surgical resection (limited because of the often aggressive course of this tumor type) and chemotherapy and radiation therapy (palliative role to minimize symptoms of advanced disease). 

Small-Cell Lung Cancer
Patients with SCLC often have widespread disease at the time of diagnosis. Rapid clinical deterioration in patients with chest masses often indicates SCLC

  1. Oat cell carcinoma Oat cell carcinoma: 13% of all lung cancers. Most aggressive type, greater tendency to metastasize than Non-Small Cell Lung Cancer Strongly related to cigarette smoking often occurs within the mainstem bronchi and segmental bronchi; 80% of cases have hilar and mediastinal node involvement. Symptoms: Paraneoplastic syndrome: syndrome of inappropriate antidiuretic hormone (SIADH), Hyponatremia, fluid retention, weakness, and fatigue, Ectopic adrenocorticotropic hormone (ACTH) production, Hypokalemia, hyponatremia, hyperglycemia, lethargy, and confusion. Treatment for Oat cell carcinoma, Surgery rarely indicated even in those with limited stage disease because of the need for immediate systemic therapy and chemotherapy and radiation therapy offers the best hope for prolonged survival and quality of life. Majority of the patients respond to chemotherapy and radiation therapy but recurrence rate is very high. Two-thirds of patients demonstrate evidence of extensive disease at the time of diagnosis. 
  2. Non-Bronchogenic Carcinomas. Undifferentiated non-small cell lung cancer (NSCLC). Non-bronchogenic carcinomas undifferientated non-small cell lung cancer (NSCLC) :
Knowing the stage of Lung Cancer is important because treatment is often decided according to the stage of a Lung cancer. TNM staging system. TNM staging takes the following factors into account. The size of the Lung Cancer (T). Whether Lung Cancer cells have spread into the lymph nodes (N) whether the Lung Cancer has spread anywhere else in the body – secondary cancer or metastases (M)
Stage of Lung cancer TNM (Tumor, Nodes, Metastases) system of staging
TNM Stage of Lung cancer Description:
Primary tumor (T) 

  • TX; Primary tumor cannot be assessed, or tumor proven by the presence of malignant cells in sputum or bronchial washings but not visualized by imaging or bronchoscopy. 
  • T0 : No evidence of primary tumor 
  • Tis : Carcinoma in situ 
  • T1 : Tumor 3 cm in greatest dimension, surrounded by lung or visceral pleura, without bronchoscopic evidence of invasion more proximal than the lobar bronchus (i.e., not in the main bronchus) 
  • T2: Tumor with any of the following features of size or extent: 3 cm in greatest dimension. Involves main bronchus, 2 cm distal to the carina Invades the visceral pleura Associated with atelectasis or obstructive pneumonitis that extends to the hilar region but does not involve the entire lung. 
  • T3 : Tumor of any size that directly invades any of the following: chest wall (including superior sulcus tumors), diaphragm, mediastinum pleura, parietal pericardium; or tumor in the main bronchus, 2 cm distal to the carina, but without involvement of the carina; or associated atelectasis or obstructive pneumonitis of the entire lung 
  • T4: Tumor of any size that invades any of the following: mediastinum, heart, great vessels, trachea, esophagus, vertebral body, carina; or tumor with a malignant pleural or pericardial effusion, b or with satellite tumor nodule(s) within the ipsilateral primary-tumor lobe of the lung 

Regional lymph nodes (N)

  • NX Regional lymph nodes cannot be assessed 
  • N0 No regional lymph node metastasis 
  • N1 Metastasis to ipsilateral peribronchial and/or ipsilateral hilar lymph nodes, and intrapulmonary nodes involved by direct extension of the primary tumor 
  • N2 Metastasis to ipsilateral mediastinal and/or subcarinal lymph node(s) 
  • N3 Metastasis to contralateral mediastinal, contralateral hilar, ipsilateral, or contralateral scalene, or supraclavicular lymph node(s) 

Distant Metastasis (M)

  • MX Presence of distant metastasis cannot be assessed 
  • M0 No distant metastasis 
  • M1 Distant metastasis present 

Stage grouping (TNM subsets):

  • Stage IA (T1 N0 M0), IB (T2 N0 M0). Most common form of early lung cancer located only in the lungs. Detected on routine chest X-ray in patients who present for unrelated medical condition or routine examination. Treatment-surgical resection. 
  • Stage IIA (T1 N1 M0), IIB (T2 N1 M0, T3 N0 M0). Tumors in the lung and lymph nodes (hilar and bronchopulmonary nodes). Treatment-surgical resection and adjuvant radiation or chemotherapy, or both. Induction chemotherapy before surgery is being investigated. Patients with significant co-morbid disease surgery may not be an option. 
  • Stage IIIA (T3 N1 M0, T1 N2 M0, T2 N2 M0, T3 N2 M0) Cancer in the lung and lymph nodes on the same side of the chest. T3 tumors involving the main stem bronchi produce hemoptysis, Dyspnea, wheezing, atelectasis, and post obstructive pneumonia. T3 tumors involving the pericardium or diaphragm may be symptomatic but those involving the chest wall usually cause pain. Nodal disease is often asymptomatic, if extensive nodal disease may cause compression of the proximal airways and superior vena cava syndrome. Treatment—selected cases surgical resection (T3NO-1), commonly multi-modality therapy with chemotherapy being primary form of treatment; multiple trials of combined chemotherapy, radiation with or without surgery are under investigation. Stage 
  • IIIB (T4 N0 M0, T4 N1 M0, T4 N2 M0, T1 N3 M0, T2 N3 M0, T3 N3 M0, T4 N3 M0) Cancer has spread to the lymph nodes on the opposite side of the chest. T4 tumors invade the mediastinum structures, and/or malignant pleural effusions. N3—metastases. Treatment—chemotherapy and radiation therapy; in rare exceptions, surgery may be considered. 
  • Stage IV (Any T Any N M1) Evidence of metastatic disease. Treatment often palliative (to relieve symptoms). Clinical trials may offer some survival benefit. 

Like many other neoplasm disease Complications of Lung Cancer occurs when lung cancer metastasized to other organ, outside the Lung. Disease progression and metastasis cause various complications. Early stage and localized disease may be asymptomatic. Symptoms are often medically treated and attributed to conditions such as bronchitis, pneumonia, and chronic obstructive pulmonary disease. Symptoms: cough & wheezing, increased sputum production, hemoptysis, Dyspnea, pneumonia, pleural effusions.
Advanced disease predominant at time of diagnosis related to tumor growth and compression of adjacent structures. When the primary tumor spreads to intrathoracic structures, complications may include tracheal obstruction; esophageal compression with dysphagia; phrenic nerve paralysis with hemidiaphragm elevation and dyspnea; sympathetic nerve paralysis with Horner’s syndrome with ptosis, miosis, hemifacial anhydrosis, clubbing, hypertrophic osteoarthropathy, bone pain, fatigue, dysphagia from esophageal compression, wheezing or stridor, phrenic nerve paralysis with elevated hemidiaphragm, arrhythmias and heart failure (from pericardial involvement), hypoxia related to lymphangitic spread, superior vena cava syndrome (swelling of the face, neck and upper extremities and related to compression of blood vessels in the neck and upper thorax.
Symptoms: chronic cough, Dyspnea, weight loss, increased sputum production, hemoptysis, hoarseness (involvement of the laryngeal nerve), pleural effusions and atelectasis, chronic pain, pain over the shoulder and medial scapula, arm pain with or without muscle wasting along ulnar distribution,
Lung cancer usually cause breathing and heart problems such as:

  • Pleural effusion 
  • Pericardial effusion 
  • Coughing up large amounts of bloody sputum. 
  • Collapse of a lung (pneumothorax). 
  • Blockage of the airway (bronchial obstruction). 
  • Recurrent infections, such as pneumonia. 

Other complications are anorexia and weight loss, sometimes leading to cachexia, digital clubbing, and hypertrophic osteoarthropathy. Endocrine syndromes may involve production of hormones and hormone precursors.
Extra thoracic spread of disease: adrenal glands (50%), liver (30%), brain (20%), bone (20%), kidneys (15%), scalene lymph nodes. Prognosis remains poor and has improved very slightly despite medical advances: <14% combined 5-year survival rate
A common treatment method of Lung Cancer is Surgery, chemotherapy and radiotherapy is all classified as a treatment for lung cancer. Knowing the stage of Lung Cancer is important because treatment is often decided according to the stage of a Lung cancer. Lung cancer accounts for more deaths than prostate, breast, and colon cancer combined. The 1-year survival rate remains approximately 41%, and the 5-year survival rate is 15%. Only 16% of lung cancers are found at an early, localized stage, when the 5-year survival rate is 49%. The survival rate for lung cancer has not improved over the last 10 years. 

Common treatment methods of Lung Cancer: 
Surgery Treatment for Lung Cancer 
The treatment of choice for non-small cell lung cancer, Stage IA, IB, IIA, IIB, and selected cases of stage IIIA : lobectomy (removal of a lobe of the lung), pneumonectomy (removal of one lung), wedge resection or segmentectomy for patients with inadequate pulmonary reserve who cannot tolerate lobectomy, VATS (Video Assisted Thoroscopic Surgery), palliative surgery. Before surgery patient must know the risk factor from Lung Cancer Surgery; Risks from lung cancer surgery include damage to structures in or near the lungs, general risks related to surgery, and risks from general anesthesia 
Patient education before surgery: patient understands surgical procedure, incision, placement of chest tubes; smoking cessation before surgery to reduce pulmonary complications pain control; bronchodilators, coughing and deep-breathing exercises, early ambulation after surgery. 
After surgery : assess respiratory function (respiratory rate, level of dyspnea, use of accessory muscles, and arterial blood gases); monitor chest tube drainage and air leaks, monitor oxygen saturation at rest and ambulation, assess pain control, chest physical therapy (bronchial drainage positions, deep breathing, coughing) early ambulation,monitor for atrial arrhythmias ; discharge planning and home care arrangements. 

Chemotherapy Treatment for Lung Cancer 
Researchers are continually looking at different ways of combining new and old drugs for advanced non-small cell lung cancer. 
Chemotherapy Treatment for Non-Small Cell Lung Cancer 

  • Customize treatment: Erlotinib (Tarceva) for people whose tumors have epidermal growth factor receptors, a genetic mutation. Gefitinib (Iressa) effective in people whose lung tumors have similar genetic mutations. 
  • Targeted treatments for advanced non-small cell lung cancer; Sunitinib (Sutent) works by cutting off blood supply and blockingnthe cancer cells their ability to grow. Sorafenib (Nexavar) suppresses receptors for vascular endothelial growth factor platelet derived growth factor—plays a critical role in the growth of blood vessels that feed the cancer (angiogensis). 
  • Combined methods are the treatment of choice for selected cases of stage IIIA and IIIB; Cispatin, Paclitaxel and Gemcitabine, Gemcitabine and Vinorelbine, Carboplatin and Paclitaxel and radiation, Cisplatin and Vinblastine and radiation 
  • Stage IV; Carboplatin and Paclitaxel, Carboplatin and Gemcitabine, Cisplatin and Vinorelbine, Docetaxel and Gemcitabine, Pemetrexed, Chemotherapy combined with Cetuximab (Erbitux): Cetuximab binds to epidermal growth factor receptors (EGFR), preventing a series of reactions in the cell that lead to lung cancer. 
  • Progression of disease: Single-agent Docetaxel, Gemcitabine, Paclitaxel 
  • Investigational New treatment approaches are being investigated all the time. Mage-A3 vaccine and non-small cell lung cancer, Bortezomib (Velcade) proteasome inhibitors destroys cancer cells 

Chemotherapy Treatment for Small-Cell Lung Cancer 

  • Limited-stage disease; Pulmonary resection stage I or stage II, Etoposide and Cisplatin and Radiation, Etoposide and Carboplatin 
  • Extensive stage disease: Etoposide and Carboplatin +/− Paclitaxel, Adriamycin, Cyclophosphamide 
  • Investigational: Vaccine-autologous dendritic cell-adenovirus p53 

Chemotherapy treatment Complications, Myelosuppression (infection, anemia, bleeding), nephrotoxicity, nausea and vomiting, mucositis (inflammation of the mucous membranes), fatigue, SIADH and hyponatremia, hypotension, anaphylaxis, alopecia (hair loss), neurotoxicity (peripheral neuropathies, central nervous system toxicity), cardiomyopathy, arrhythmias, congestive heart failure, myocardial infarction, pneumonitis or pulmonary fibrosis, taste changes. Patient education (chemotherapy): chemotherapeutic agents, treatment schedule, adverse effects of drugs. 

Radiation therapy Treatment for Lung Cancer 

  • External beam radiotherapy used as an adjunct to surgery to decrease tumor size, to cure patients considered inoperable for medical or pathologic reasons, or to decrease symptoms. Radiation after surgery: to improve resectability of tumor & to sterilize microscopic disease. Radiation after surgery: to treat disease confined to one hemi thorax with hilar or mediastinum nodal metastasis & to reduce local recurrence (if positive surgical margins exist). Prophylactic cranial irradiation: limited disease small-cell lung cancer to reduce reoccurrence in CNS. 
  • Brachytherapy placement of radioactive sources (seeds or catheter) directly into or adjacent to a tumor. Intraoperative: reduce local recurrence. Symptom palliation (relief of pain from bone metastases, hemoptysis, superior vena cave syndrome, airway obstruction). 

Complications of radiation therapy: Dyspnea, cough, initial increase in mucus production, and then dry cough, fatigue, skin erythema, esophagitis and dysphagia, pneumonitis, lung fibrosis. Patient education: radiation therapy: indelible markings, treatment schedule, site-specific adverse effects (within treatment field). 

Treatment alternatives 
Neoadjuvant is therapy given before the primary therapy to improve effectiveness (e.g., chemotherapy or radiation before surgery). Adjuvant treatments are equally beneficial and often given concurrently or immediately following one another to maximize effectiveness (e.g., surgery and adjuvant chemotherapy after surgery), multimodality is therapy that combines more than one method of treatment (e.g. concurrent chemotherapy and radiation, such as, adjuvant and Neoadjuvant) 

Home care considerations 
After lung surgery: smoking cessation, control of incision pain, wound care, breathing exercises and coughing, pursed lip breathing exercises, maintain fluid intake, maintaining your nutrition, resume activity, regaining arm and shoulder function. 
During and after radiation therapy: monitor side effects of radiation therapy and report any change in. Symptoms: Dyspnea, fatigue is common lasting 4–6 weeks after therapy, good nutrition, liquid diet supplement during periods of esophagitis, avoid wearing tight clothes, skin care. 
During and after chemotherapy, advise patients: To identify all treatment related side effects and report changes Fatigue may last weeks to months To plan their day, and allow for periods of rest Try activities such as yoga, exercise, meditation, and guided imagery Keep a diary and document symptoms, activity level, nutrition, treatments, and emotions To monitor effectiveness of pain medications To monitor for any signs of infection, such as an increased temperature, redness or swelling, and that the latter symptoms may not be present during weeks of impaired immunity following chemotherapy administration Monitor weight change and appetite Nutritional supplements 
Pulmonary rehabilitation programs: exercise strengthening, breathing exercises, walking program, nebulizers/aerosol medication delivery, disease specific instruction and support. Support groups: Lung Cancer specific, Better Breathers Club a support group sponsored by the American Lung Association for patients with chronic lung disease. Hospice: dignified dying, pain management, end of life issues, patient/family support.

Nursing Assessment 
Patient History Establish a history of persistent cough, chest pain, Dyspnea, weight loss, or hemoptysis. Smoking history, other risk factors (family history, occupational risks), associated diseases (COPD, tuberculosis, and emphysema), symptom description and onset. Ask if the patient has experienced a change in normal respiratory patterns or hoarseness. Some patients initially report pneumonia, bronchitis, and epigastria pain, symptoms of brain metastasis, arm or shoulder pain, or swelling of the upper body. Ask if the sputum has changed color, especially to a bloody, rusty, or purulent hue. Elicit a history of exposure to risk factors by determining if the patient has been exposed to industrial or air pollutants. Check the patient’s family history for incidence of lung cancer 
Physical examination The clinical findings of lung cancer may be localized to the lung or may result from the regional or distant spread of the disease. Lung auscultation, respiratory rate and depth, palpitation of supraclavicular area for tumor or lymphatic involvement or both, clubbing, nicotine stains to skin, hair, teeth. Lung cancer clinical manifestations depend on the type and location of the tumor. Because the early stages of this disease usually produce no symptoms, it is most often diagnosed when the disease is at an advanced stage. In 10% to 20% of patients, lung cancer is diagnosed without any symptoms, usually from an abnormal finding on a routine chest x-ray. Auscultation may reveal a wheeze if partial bronchial obstruction has occurred. Auscultate for decreased breath sounds, rales, or rhonchi. Note signs of an airway obstruction, such as extreme shortness of breath, the use of accessory muscles, abnormal retractions, and stridor. Monitor the patient for oxygenation problems, such as increased heart rate, decreased blood pressure, or an increased duskiness of the oral mucous membranes. Metastases to the mediastinum lymph nodes may involve the laryngeal nerve and may lead to hoarseness and vocal cord paralysis. The superior vena cava may become occluded with enlarged lymph nodes and cause superior vena cava syndrome; note edema of the face, neck, upper extremities, and thorax. 
Psychosocial examination The patient is faced with a psychological adjustment to the diagnosis of a chronic illness that frequently results in death. Patient undergoes major lifestyle changes as a result of the physical side effects of cancer and its treatment. Interpersonal, social, and work role relationships change. Evaluate the patient for evidence of altered moods such as depression or anxiety, and assess the patient’s coping mechanisms and support system. 

Diagnostic tests For Lung Cancer 
Chest radiographs plain anterior-posterior and lateral views not reliable to find lung tumors in their earliest stage. Chest Computed Tomography (CT) three-dimensional image of the lungs and lymph nodes (can detect tumors as small as 5 millimeters). CT is only about 80% accurate in predicting mediastinum node involvement. Spiral computed tomography of the chest. Magnetic Resonance Imaging (MRI) 92% accuracy in the diagnosis of mediastinum invasion. Positron Emission Tomography (PET) scan is based upon increased glucose metabolism in cancer cells. The PET scan uses a glucose analogue radiopharmaceutical to identify increased glycolysis in tumor tissues. The PET scan is a highly sensitive test in the diagnosis and staging of lung cancer. Bronchoscopic detection of tumor auto fluorescence could improve cure rates in selected groups at high-risk. Sputum cytology Percutaneous transthoracic needle biopsy Fine needle aspiration or biopsy Bronchoscopy. Mediastinoscopy to evaluate lymph node involvement. Scalene node biopsy (evaluate lymph node involvement) Photodynamic therapy; An injection of a light-sensitive agent with uptake by cancer cells, followed by exposure to a laser light within 24 to 48 hours, will result in fluorescence of cancer cells or cell death. Especially helpful in identifying developing cancer cells or “carcinoma in-situ.” Also used to determine the extent of disease and the response to treatment (experimental). Assessment of distant metastasis: Abdominal CT (identify adrenal or liver metastasis), Head CT, MRI (brain), Bone scan; Thoracentesis (detect malignant cells in the pleural fluid). 

Nursing Diagnosis for Lung Cancer 
Common Nursing diagnosis found in nursing care plans for patient with Lung Cancer: 
Impaired gas exchange related to Removal of lung tissue, altered oxygen supply. Ineffective Airway Clearance May be related to Increased amount or viscosity of secretions, Restricted chest movement, pain, Fatigue, weakness Acute Pain May be related to Surgical incision, tissue trauma, and disruption of intercostals nerves, Presence of chest tube, Cancer invasion of pleura, chest wall Fear/Anxiety [specify level] May be related to Situational crises, Threat to or change in health status, Perceived threat of death. Deficient Knowledge [Learning Need] regarding condition, treatment, prognosis, self-care, and discharge needs. May be related to Lack of exposure, unfamiliarity with information or resources, Information misinterpretation, Lack of recall 

Sample Nursing care Plan for Lung Cancer with interventions and rationale 

Impaired gas exchange 
May be related to: 

  • Removal of lung tissue (Surgery Treatment for Lung Cancer) 
  • Altered oxygen supply hypoventilation 
  • Decreased oxygen-carrying capacity of blood (blood loss). 

Nursing outcomes and evaluation criteria client will: 
Respiratory status: gas exchange, Demonstrate improved ventilation and adequate oxygenation of tissues by arterial blood gases (ABGs) within client normal range, be free of symptoms of respiratory distress, the patient will maintain adequate ventilation. The patient will maintain a patent airway. 

Nursing Interventions Nursing care Plan for Lung Cancer Nursing diagnosis Impaired gas exchange: Respiratory Management: 
Note respiratory rate, depth, and ease of respirations. Observe for use of accessory muscles, pursed-lip breathing, or changes in skin or mucous membrane Rationale Respirations may be increased as a result of compensatory mechanism to accommodate for loss of lung tissue or pain. Auscultate lungs for air movement and abnormal breath sounds. Rationale Consolidation and lack of air movement on operative side are normal in the client who has had a pneumonectomy; but in a client who has had a lobectomy should demonstrate normal airflow in remaining lobes. Investigate restlessness and changes in mentation and level of consciousness. Rationale May indicate increased hypoxia or complications such as mediastinum shift in a client who has had a pneumonectomy when accompanied by tachypnea, tachycardia, and tracheal deviation. Assess client response to activity. Encourage rest periods, limiting activities to client tolerance. Rationale Increased oxygen consumption and demand and stress of surgery may result in increased Dyspnea and changes in vital signs with activity; however, early mobilization is desired to help prevent pulmonary complications and to obtain and maintain respiratory and circulatory efficiency. Adequate rest balanced with activity can prevent respiratory compromise. Note development of fever. Rationale Fever within the first 24 hours after surgery is frequently due to atelectasis. Temperature elevation within postoperative day 5 to 10 usually indicates an infection, such as wound or systemic. 

Airway Management: 
Maintain patent airway by positioning, suctioning, and use of airway adjuncts. Rationale Airway obstruction impedes ventilation, impairing gas exchange. (Refer to ND: ineffective Airway Clearance). Reposition frequently, placing client in sitting and supine to side positions. Rationale Maximizes lung expansion and drainage of secretions. Avoid positioning client with a pneumonectomy on the operative side. Rationale Research shows that positioning clients following lung surgery with their “good lung down” maximizes oxygenation by using gravity to enhance blood flow to the healthy lung, thus creating the best possible match between ventilation and perfusion. Encourage and assist with deep-breathing exercises and pursed lip breathing, as appropriate. Rationale Promotes maximal ventilation and oxygenation and reduces or prevents atelectasis. Administer supplemental oxygen via nasal cannula, partial rebreathing mask, or high-humidity face mask, as indicated. Rationale Maximizes available oxygen, especially while ventilation is reduced because of anesthetic, depression, or pain, and during period of compensatory physiological shift of circulation to remaining functional alveolar units. Assist with and encourage use of incentive spirometer. Rationale Prevents or reduces atelectasis and promotes reexpansion of small airways. Monitor and graph ABGs and pulse oximetry readings. Note hemoglobin (Hgb) levels. Rationale Decreasing PaO2 or increasing PaCO2 may indicate need for ventilatory support. Significant blood loss results in decreased oxygen-carrying capacity, reducing PaO2. 

Tube Care Chest: 
Maintain patency of chest drainage system following lobectomy and segmental wedge resection procedures. Rationale Drains fluid from pleural cavity to promote re expansion of remaining lung segments. Note changes in amount or type of chest tube drainage. Rationale Bloody drainage should decrease in amount and change to a more serous composition as recovery progresses. A sudden increase in amount of bloody drainage or return to frank bleeding suggests thoracic bleeding or a hemothorax, sudden cessation suggests blockage of tube, requiring further evaluation and intervention. Observe for presence of bubbling in water-seal chamber. Rationale Air leaks appearing immediately postoperatively are not uncommon, especially following lobectomy or segmental resection; however, this should diminish as healing progresses. Prolonged or new leaks require evaluation to identify problems in client versus a problem in the drainage system. 

Nursing diagnosis Ineffective Airway Clearance 
May be related to: 

  • Increased amount or viscosity of secretions 
  • Restricted chest movement, pain 
  • Fatigue, weakness 

Nursing Outcomes and Evaluation Criteria Client Will: 

  • Respiratory Status: Airway Patency 
  • Demonstrate patent airway, with fluid secretions easily expectorated, clear breath sounds, and noiseless respirations. 

Nursing Interventions nursing care Plan for Lung Cancer Nursing diagnosis Ineffective Airway Clearance 

  • Auscultate chest for character of breath sounds and presence of secretions. Rationale: Noisy respirations, rhonchi, and wheezes are indicative of retained secretions or airway obstruction. 
  • Assist client with and provide instruction in effective deep breathing, coughing in upright position (sitting), and splinting of incision. Rationale Upright position favors maximal lung expansion, and splinting improves force of cough effort to mobilize and remove secretions. Splinting may be done by nurse placing hands anteriorly and posterior over chest wall and by client, with pillows, as strength improves. 
  • Observe amount and character of sputum and aspirated secretions. Investigate changes, as indicated. Rationale Increased amounts of colorless (or blood-streaked) or watery secretions are normal initially and should decrease as recovery progresses. Presence of thick, tenacious, bloody, or purulent sputum suggests development of secondary problems for example, dehydration, pulmonary edema, local hemorrhage, or infection that require correction or treatment. 
  • Suction if cough is weak or breathe sounds not cleared by cough effort. Avoid deep endotracheal and nasotracheal suctioning in client who has had pneumonectomy if possible. Rationale Suctioning increases risk of hypoxemia and mucosal damage. Deep tracheal suctioning is generally contraindicated. If suctioning is unavoidable, it should be done gently and only to induce effective coughing. 
  • Encourage oral fluid intake, within cardiac tolerance. Rationale Adequate hydration aids in keeping secretions loose and enhances expectoration. 
  • Assess for pain and discomfort and medicate on a routine basis and before breathing exercises. Rationale Encourages client to move, cough more effectively, and breathe more deeply to prevent respiratory insufficiency. 
  • Provide and assist client with incentive spirometer and postural drainage and percussion, as indicated. Rationale Improves lung expansion and ventilation and facilitates removal of secretions. Note: Postural drainage may be contraindicated in some clients, and, in any event, must be performed cautiously to prevent respiratory embarrassment and incision discomfort. 
  • Use humidified oxygen and ultrasonic nebulizer. Provide additional fluids intravenously (IV), as indicated. Rationale Maximal hydration helps promote expectoration. Impaired oral intake necessitates IV supplementation to maintain hydration. 
  • Administer bronchodilators, expectorants, and analgesics, as indicated. Rationale Relieves bronchospasm to improve airflow. Expectorants increase mucus production and liquefy and reduce viscosity facilitating removal of secretions. 

Nursing Diagnosis Acute Pain 
May be related to: 

  • Surgical incision, tissue trauma, and disruption of intercostals nerves 
  • Presence of chest tubes 
  • Cancer invasion to pleura or chest wall 

Nursing Outcomes and Evaluation Criteria Client Will: 

  • Pain Level 
  • Report pain relieved or controlled. 
  • The patient will express feelings of comfort and decreased pain 
  • Appear relaxed and sleep or rest appropriately. 
  • Participate in desired as well as needed activities. 

Nursing Interventions and rationale nursing care Plan for Lung Cancer with nursing diagnosis Acute Pain 

  • Ask client about pain. Determine pain location and characteristics. Have client rate intensity on a scale of 0 to 10. Rationale Helpful in evaluating cancer related pain symptoms, which may involve viscera, nerve, or bone tissue. Use of rating scale aids client in assessing level of pain and provides tool for evaluating effectiveness of analgesics, enhancing client control of pain. 
  • Assess client verbal and nonverbal pain cues. Rationale Discrepancy between verbal and nonverbal cues may provide clues to degree of pain and need for and effectiveness of interventions. 
  • Note possible pathophysiological and psychological causes of pain. Rationale Fear, distress, anxiety, and grief can impair ability to cope. Posterolateral incision is more uncomfortable for client than an anterolateral incision. Discomfort can greatly increase with the presence of chest tubes. 
  • Evaluate effectiveness of pain control. Encourage sufficient medication to manage pain; change medication or time span as appropriate. Rationale Pain perception and pain relief are subjective, thus pain management is best left to client’s discretion. If client is unable to provide input, the nurse should observe physiological and nonverbal signs of pain and administer medications on a regular basis. 
  • Encourage verbalization of feelings about the pain. Rationale Fears and concerns can increase muscle tension and lower threshold of pain perception. 
  • Provide comfort measures such as frequent changes of position, back rubs, and support with pillows. Encourage use of relaxation techniques including visualization, guided imagery, and appropriate Diversional activities. Rationale Promotes relaxation and redirects attention. Relieves discomfort and therapeutic effects of analgesia. 
  • Schedule rest periods, provide quiet environment. Rationale Decreases fatigue and conserves energy, enhancing coping abilities. 
  • Assist with self care activities, breathing, arm exercises, and ambulation. Rationale Prevents undue fatigue and incision strain. Encouragement and physical assistance and support may be needed for some time before client is able or confident enough to perform these activities because of pain or fear of pain. 
  • Assist with patient-controlled analgesia PCA or analgesia through epidural catheter. Administer intermittent analgesics routinely, as indicated, especially 45 to 60 minutes before respiratory treatments, and deep-breathing and coughing exercises. Rationale Maintaining a constant drug level avoids cyclic periods of pain, aids in muscle healing, and improves respiratory function and emotional comfort and coping. 

Nursing Diagnosis Fear/Anxiety [specify level] 
May be related to: 

  • Situational crises 
  • Threat to or change in health status 
  • Perceived threat of death 

Nursing Outcomes and Evaluation Criteria Client Will: 

  • Fear Self-Control or Anxiety Self-Control 
  • Acknowledge and discuss fears and concerns. 
  • Demonstrate appropriate range of feelings and appear relaxed and resting appropriately. 
  • Verbalize accurate knowledge of situation. 
  • Report beginning use of individually appropriate coping strategies. 

Nursing Interventions and rationale nursing care Plan for Lung Cancer with nursing diagnosis Fear/Anxiety: 

  • Evaluate client and significant other (SO) level of understanding of diagnosis. Rationale Client and SO are hearing and assimilating new information that includes changes in self-image and lifestyle. Understanding perceptions of those involved sets the tone for individualizing care and provides information necessary for choosing appropriate interventions. 
  • Acknowledge reality of client’s fears and concerns and encourage expression of feelings. Rationale Support may enable client to begin exploring and dealing with the reality of cancer and its treatment. Client may need time to identify feelings and even more time to begin to express them. 
  • Provide opportunity for questions and answer them honestly. Be sure that client and care providers have the same understanding of terms used. Rationale Establishes trust and reduces misperceptions or misinterpretation of information. 
  • Accept, but do not reinforce, client’s denial of the situation. Rationale When extreme denial or anxiety is interfering with progress of recovery, the issues facing client need to be explained and resolutions explored. 
  • Note comments and behaviors indicative of beginning acceptance or use of effective strategies to deal with situation. Rationale Fear and anxiety will diminish as client begins to accept and deal positively with reality. Indicator of client’s readiness to accept responsibility for participation in recovery and to “resume life.” 
  • Involve client and SO in care planning. Provide time to prepare for events and treatments. Rationale May help restore some feeling of control and independence to client who feels powerless in dealing with diagnosis and treatment. 
  • Provide for client’s physical comfort. Rationale It is difficult to deal with emotional issues when experiencing extreme or persistent physical discomfort. 

Nursing Diagnosis Deficient Knowledge Learning Need regarding condition, treatment, prognosis, self-care, and discharge needs Related to: 

  • Lack of exposure, unfamiliarity with information or resources 
  • Information misinterpretation 
  • Lack of recall 

Nursing Outcomes and Evaluation Criteria Disease Process and Treatment Regimen Client Will:

  • Verbalize understanding of ramifications of diagnosis, prognosis, and possible complications. 
  • Participate in learning process Knowledge of the Disease Process. 
  • Verbalize understanding of therapeutic regimen. 
  • Correctly perform necessary procedures and explain reasons for the actions. 
  • Initiate necessary lifestyle changes. 

Nursing Interventions and rationale nursing care Plan for Lung Cancer with nursing diagnosis Deficient Knowledge Learning Need regarding condition, treatment, prognosis, self-care, and discharge needs: 

  • Discuss diagnosis, current and planned therapies, and expected outcomes. Rationale Provides individually specific information, creating knowledge base for subsequent learning regarding home management. Radiation or chemotherapy may follow surgical intervention, and information is essential to enable the client and SO to make informed decisions. 
  • Reinforce surgeon’s explanation of particular surgical procedure, providing diagram as appropriate. Incorporate this information into discussion about short- and long-term recovery expectations. Rationale Length of rehabilitation and prognosis depend on type of surgical procedure, preoperative physical condition, and duration and degree of complications. 
  • Discuss necessity of planning for follow-up care before discharge. Rationale Follow-up assessment of respiratory status and general health is imperative to assure optimal recovery. Also provides opportunity to readdress concerns or questions at a less stressful time. 
  • Identify signs and symptoms requiring medical evaluations, such as changes in appearance of incision, development of respiratory difficulty, fever, increased chest pain, and changes in appearance of sputum. Rationale Early detection and timely intervention may prevent or minimize complications. Stress importance of avoiding exposure to smoke, air pollution, and contact with individuals with upper respiratory infections (URIs). 
  • Review nutritional and fluid needs. Suggest increasing protein and use of high-calorie snacks as appropriate. Rationale Meeting cellular energy requirements and maintaining good circulating volume for tissue perfusion facilitate tissue regeneration and healing process. 
  • Identify individually appropriate community resources, such as American Cancer Society, visiting nurse, social services, and home care. Rationale Agencies such as these offer a broad range of services that can be tailored to provide support and meet individual needs. 
  • Help client determine activity tolerance and set goals. Rationale Weakness and fatigue should decrease as lung heals and respiratory function improves during recovery period, especially if cancer was completely removed. If cancer is advanced, it is emotionally helpful for client to be able to set realistic activity goals to achieve optimal independence. 
  • Evaluate availability and adequacy of support system(s) and necessity for assistance in self-care and home management. Rationale General Weakness and activity limitations may reduce individual’s ability to meet own needs. 
  • Encourage alternating rest periods with activity and light tasks with heavy tasks. Stress avoidance of heavy lifting and isometric or strenuous upper body exercise. Reinforce physician’s time limitations about lifting. Rationale Generalized weakness and fatigue are usual in the early recovery period but should diminish as respiratory function improves and healing progresses. Rest and sleep enhance coping abilities, reduce nervousness (common in this phase), and promote healing. Note: Strenuous use of arms can place undue stress on incision because chest muscles may be weaker than normal for 3 to 6 months following surgery. 
  • Recommend stopping any activity that causes undue fatigue or increased shortness of breath. Rationale Exhaustion aggravates respiratory insufficiency. 
  • Instruct and provide rationale for arm and shoulder exercises. Have client or SO demonstrate exercises. Encourage following graded increase in number and intensity of routine repetitions. Rationale Simple arm circles and lifting arms over the head or out to the affected side are initiated on the first or second postoperative day to restore normal range of motion ROM of shoulder and to prevent ankylosis of the affected shoulder. 
  • Encourage inspection of incisions. Review expectations for healing with client. Rationale Healing begins immediately, but complete healing takes time. As healing progresses, incision lines may appear dry with crusty scabs. Underlying tissue may look bruised and feel tense, warm, and lumpy (resolving hematoma). 
  • Instruct client and SO to watch for and report places in incision that do not heal or reopening of healed incision, any drainage (bloody or purulent), and localized area of swelling with redness or increased pain that is hot to touch. Rationale Signs and symptoms indicating failure to heal, development of complications requiring further medical evaluation and intervention. 
  • Suggest wearing soft cotton shirts and loose fitting clothing, cover portion of incision with pad, as indicated, and leave incision open to air as much as possible. Rationale Reduces suture line irritation and pressure from clothing. Leaving incisions open to air promotes healing process and may reduce risk of infection. 
  • Shower in warm water, washing incision gently. Avoid tub baths until approved by physician. Rationale Keeps incision clean and promotes circulation and healing. 
  • Support incision with butterfly bandages as needed when sutures and staples are removed. Rationale Aids in maintaining approximation of wound edges to promote healing. 

Patient Teaching, Discharge And Home Healthcare Guidelines 
Patient Teaching, Discharge and Home Healthcare Guidelines for patient with Lung Cancer usually divide in to before surgery and post surgery. Be sure the patient understands any medication prescribed, including dosage, route, action, and side effects. Teach the patient about medical procedure before surgery and post surgery. Teach the patient how to maximize her or his respiratory effort. 

Before surgery, supplement and reinforce what the physician has told the patient about the disease and the operation. Teach the patient about postoperative procedures and equipment. Discuss urinary catheterization, chest tubes, endotracheal tubes, dressing changes, and I.V. therapy. If the patient is receiving chemotherapy or radiation therapy, explain possible adverse effects of these treatments. Teach him ways to avoid complications, such as infection. Also review reportable adverse effects. Educate high-risk patients about ways to reduce their chances of developing lung cancer or recurrent cancer. Refer smokers to local branches of the American Cancer Society or Smokenders. Provide information about group therapy, individual counseling, and hypnosis. Urge all heavy smokers older than age 40 to have a chest X-ray annually and cytologic sputum analysis every 6 months. Also encourage patients who have recurring or chronic respiratory tract infections, chronic lung disease, or a nagging or changing cough to seek prompt medical evaluation. 

Post Surgery, Provide the patient with the names, addresses, and phone numbers of support groups, such as the American Cancer Society, the National Cancer Institute, the local hospice, the Alliance for Lung Cancer Advocacy, Support & Education (ALCASE), and the Visiting Nurses Association Teach the patient to recognize the signs and symptoms of infection at the incision site, including redness, warmth, swelling, and drainage. Explain the need to contact the physician immediately Warn an outpatient to avoid tight clothing, sunburn, and harsh ointments on his chest. Teach him exercises to prevent shoulder stiffness. Teach him how to cough and breathe deeply from the diaphragm and how to perform range-of-motion exercises. Reassure him that analgesics and proper positioning will help to control postoperative pain.