Although almost all men older than 50 have some prostatic enlargement, with benign prostatic hyperplasia (BPH), the prostate gland enlarges sufficiently to compress the urethra and cause some overt urinary obstruction. It is the most common cause of obstruction of urine flow in men. The degree of enlargement determines whether or not bladder outflow obstruction occurs. As the urethra becomes obstructed, the muscle inside the bladder hypertrophies in an attempt to assist the bladder to force out the urine. BPH may also cause the formation of a bladder diverticulum that remains full of urine when the patient empties the bladder. Depending on the size of the enlarged prostate, the age and health of the patient, and the extent of obstruction, benign prostatic hyperplasia (BPH), is treated symptomatically or surgically.

Causes for Benign prostatic hyperplasia (BPH)

A link between Benign prostatic hyperplasia (BPH) and hormonal activity suggests.  As males age, production of androgenic hormones decreases, causing an imbalance in androgen and estrogen levels and high levels of dihydrotestosterone, the main prostatic intracellular androgen.

Other causes of Benign prostatic hyperplasia (BPH) include:

• Neoplasm
• Arteriosclerosis
• Inflammation
• Metabolic Imbalance
• Nutritional disturbances.

Complications for Benign prostatic hyperplasia (BPH)

• Urinary stasis
• Urinary tract infection (UTI)
• Renal calculi
• Bladder wall trabeculation
• Detrusor muscle hypertrophy
• Bladder diverticula and saccules
• Urethral stenosis
• Hydronephrosis
• Paradoxical (overflow) incontinence
• Acute renal failure or chronic renal failure
• Acute postobstructive diuresis.

Nursing Diagnosis Benign Prostatic Hyperplasia (BPH)

Nursing Diagnosis for Benign Prostatic Hyperplasia (BPH) determine by data that we collect in nursing assessment.

Nursing Assessment nursing care plans for Benign Prostatic Hyperplasia (BPH)

BPH Clinical features depend on the extent of prostatic enlargement and on the lobes affected. Patient history, generally, men with suspected BPH have a history of frequent urination, nocturia, straining to urinate, weak stream, and an incomplete emptying of the bladder. Patient usually complains of a group of symptoms known as prostatism: decreased urine stream caliber and force, an interrupted stream, urinary hesitancy, and difficulty starting urination, which results in straining and a feeling of incomplete voiding. As the obstruction increases, the patient may report frequent urination with nocturia, dribbling, urine retention, incontinence and, possibly, hematuria.

Physical examination. Inspect and palpate the bladder for distension. Physical examination reveals a visible midline mass above the symphysis pubis, which represents an incompletely emptied bladder. Palpation discloses a distended bladder, A digital rectal exam (DRE) reveals a rubbery enlargement of the prostate, but the degree of enlargement does not consistently correlate with the degree of urinary obstruction. Some men have enlarged prostates that extend out into soft tissue without compressing the urethra. Determine the amount of pain and discomfort that is associated with the DRE.

Diagnostic tests Benign Prostatic Hyperplasia (BPH)

Several tests help to confirm Benign Prostatic Hyperplasia (BPH) diagnosis:

• Excretory urography may indicate urinary tract obstruction, hydronephrosis, calculi or tumors, and filling and emptying defects in the bladder.
• Elevated blood urea nitrogen
• Serum creatinine levels suggest impaired renal function.
• Urinalysis and urine culture
• Cystourethroscopy
• Intravenous pyelography (IVP)
• Transrectal prostatic ultrasound (TRUS)
• A prostate-specific antigen test may be performed to rule out prostatic cancer.

Nursing diagnosis nursing care plans for  Benign Prostatic Hyperplasia (BPH)

Primary nursing diagnosis:

Urinary retention (acute or chronic) related to bladder obstruction

Common nursing diagnosis found in patient with Benign Prostatic Hyperplasia (BPH)

• Acute pain
• Fear/Anxiety [specify level]
• Impaired urinary elimination
• deficient Knowledge regarding condition,prognosis, treatment, self-care, and discharge needs
• Risk for infection
• Risk for injury
• Sexual dysfunction
• Urinary retention

Nursing care plans Benign Prostatic Hyperplasia (BPH)

Common nursing diagnosis found in patient with Benign Prostatic Hyperplasia (BPH);  Urinary retention (acute or chronic), Acute pain,  Fear, Anxiety, Impaired urinary elimination,  deficient Knowledge,  Risk for infection, Risk for injury, Sexual dysfunction,

Nursing Priorities Nursing care plans for Benign Prostatic Hyperplasia (BPH)

• Relieve acute urinary retention.
• Promote comfort.
• Provide information about disease process, prognosis, and treatment needs.
• Prevent complications.
• Help client deal with psychosocial concerns.

Sample Nursing care plans for Benign Prostatic Hyperplasia (BPH) with nursing diagnosis Urinary retention (acute or chronic)

Benign Prostatic Hyperplasia (BPH), Patient Teaching Discharge And Home Healthcare Guidelines
Patient teaching discharge and home healthcare guidelines for patient with Benign Prostatic Hyperplasia (BPH). Patient usualy  need assistance with management of therapy and catheter. Provide instructions about all medications used. Provide instructions on the correct dosage, route, action, side effects, and potential drug interactions and when to notify these to the physician, Provide information about specific procedures and tests and what to expect afterward, such as catheter, bloody urine, and bladder irritation

• Instruct patients about the need to maintain a high fluid intake, to ensure adequate urine output.
• Teach the patient to monitor urinary output for 4 to 6 weeks after surgery to ensure adequacy in volume of elimination combined with a decrease in volume of retention. Teach the patient to recognize the signs of Urinary Tract Infection (UTIs). Urge him to immediately report these signs to the physician because infection can worsen the obstruction.

• After the catheter is removed, the patient may experience urinary frequency, dribbling and, occasionally, hematuria. Reassure him and family members that he’ll gradually regain urinary control
• Instruct the patient to follow the prescribed oral antibiotic regimen, and tell him the indications for using gentle laxatives.

Postoperative Patient teaching

• Provide information about sexual anatomy and function as it relates to prostatic enlargement helps client understand the implications of proposed treatments because they might affect sexual performance.
• Encourage the patient to discuss any sexual concerns he or his partner may have after surgery with the appropriate counselors.
• Reassure the patient that a session can be set up by the nurse or physician whenever one is indicated. Usually, the physician recommends that the patient have no sexual intercourse or masturbation for several weeks after invasive procedures.
• Reinforce prescribed limits on activity. Warn the patient against lifting, performing strenuous exercises, and taking long automobile rides for at least 1 month after surgery because these activities increase bleeding tendency. Also caution him not to have sexual intercourse for at least several weeks after discharge

Prevention

Instruct the patient to report any difficulties with urination to the physician immediately. Explain that BPH can recur and that he should notify the physician if symptoms of urgency, frequency, difficulty initiating stream, retention, nocturia, or bladder distension.

• Urge the patient to seek medical care immediately if he can’t void at all, if he passes bloody urine, or if develops a fever.
• Reinforce importance of medical follow-up for at least 6 months to 1 year, including rectal examination and urinalysis.

Tuberculosis TB is an infectious disease caused by bacteria (Mycobacterium tuberculosis) that are usually spread from person to person through the air. Tuberculosis (TB) is characterized by pulmonary infiltrates, formation of granulomas with caseation, fibrosis, and cavitation. People living in crowded, poorly ventilated conditions are most likely to become infected. It usually infects the lung but can occur at virtually any site in the body. HIV-infected patients are especially at risk. In patients with strains that are sensitive to the usual antitubercular agents, the prognosis is excellent with correct treatment. However, in those with strains that are resistant to two or more of the major antitubercular agents, mortality is 50%.

Pathophysiology

• The bacilli of Tuberculosis TB infect the lung, forming a tubercle (lesion).
• The tubercle:  May heal, leaving scar tissue. May continue as a granuloma, then heal, or be reactivated. May eventually proceed to necrosis, liquefaction, sloughing, and cavitation.
• The initial lesion may disseminate tubercle bacilli by extension to adjacent tissues, by way of the bloodstream, by way of the lymphatic system, or through the bronchi.
• Extrapulmonary Tuberculosis TB occurs more commonly in children and immunocompromised individuals and can involve lymph nodes, bones, joints, pleural space, pericardium, CNS, GU tissue, and the peritoneum.

Transmission

1. The term Mycobacterium is descriptive of the organism, which is a bacterium that resembles a fungus. The organisms multiply at varying rates and are characterized as acid-fast aerobic organisms that can be killed by heat, sunshine, drying, and ultraviolet light.
2. Tuberculosis TB is an airborne disease transmitted by droplet nuclei, usually from within the respiratory tract of an infected person who exhales them during coughing, talking, sneezing, or singing.
3. When an uninfected susceptible person inhales the droplet-containing air, the organism is carried into the lung to the pulmonary alveoli.
4. Most people who become infected do not develop clinical illness, because the body’s immune system brings the infection under control.

The primary infectious agent of Pulmonary Tuberculosis TB is, Mycobacterium tuberculosis, is an acid-fast aerobic rod that grows slowly and is sensitive to heat and ultraviolet light. Mycobacterium bovis and Mycobacterium avium have rarely been associated with the development of a TB infection.

Risk Factors for Pulmonary Tuberculosis

• Close contact with someone who has active Tuberculosis TB. Inhalation of airborne nuclei from an infected person is proportional to the amount of time spent in the same air space, the proximity of the person, and the degree of ventilation.
• Immunocompromised status (e.g. those with HIV infection, cancer, transplanted organs, and prolonged high-dose corticosteroid therapy)
• Substance abuse (IV or injection drug users and alcoholics)
• Any person without adequate health care (the homeless, impoverished, minorities, particularly children under age 15 years and young adults between ages 15 and 44 yrs)
• Preexisting medical conditions or special treatment (e.g. Diabetes Mellitus, chronic renal failure, malnourishment, selected malignancies, hemodialysis, transplanted organ, gastrectomy, or jejunoileal bypass)
• Immigration from countries with a high prevalence of Tuberculosis TB (southeastern Asia, Africa, Latin America, Caribbean)
• Institutionalization (e.g. long-term care facilities, psychiatric institutions, prisons)
• Living in overcrowded, substandard housing
• Being a health care worker performing high-risk activities: administration of aerosolized pentamidine and other medications, sputum induction procedures, Bronchoscopy, suctioning, coughing procedures, caring for the immunosuppressed patient, home care with the high-risk population, and administering anesthesia and related procedures (e.g. intubation, suctioning)

Clinical Manifestations

Patient may be asymptomatic or may have insidious symptoms that may be ignored.

• Constitutional symptoms; Fatigue, anorexia, weight loss, low-grade fever, night sweats, indigestion. Some patients have acute febrile illness, chills, and flu-like symptoms.
• Pulmonary signs and symptoms; Cough (insidious onset) progressing in frequency and producing mucoid or mucopurulent sputum. Hemoptysis; chest pain; dyspnea (indicates extensive involvement).
• Extrapulmonary Tuberculosis TB: pain, inflammation, and dysfunction in any of the tissues infected.

COMPLICATIONS

1. Pleural effusion
2. TB pneumonia; Tuberculosis TB can cause massive pulmonary tissue damage, with inflammation and tissue necrosis eventually leading to respiratory failure. Bronchopleural fistulas can develop from lung tissue damage, resulting in pneumothorax. The disease can also lead to hemorrhage, and pneumonia.
3. Other organ involvement with Tuberculosis TB; Small mycobacterial foci can infect other body organs, including the kidneys and the central nervous and skeletal systems.
4. The patient also might develop Serious reactions to drug therapy

• INH may produce asymptomatic elevation in liver enzymes, rare peripheral neurotoxicity, hepatitis that may, rarely, be fatal, CNS effects (dysarthria, irritability, seizures, dysphoria, diminished concentration), lupus-like syndrome, hypersensitivity reactions, and monoamine poisoning (rarely occurring with consumption of some wines and cheeses). Patients with pre-existing liver disease should be monitored closely.
• Ethambutol may cause retrobulbar optic neuritis with decreased visual acuity and decreased red-green discrimination in one or both eyes, although this occurs rarely with daily doses of 15 mg/kg/day. EMB may also cause peripheral neuritis and cutaneous reactions. Patients should have baseline visual acuity and color discrimination (Ishihara test) testing as well as monthly monitoring.
• Pyrazinamide may cause hepatotoxicity, GI symptoms, nongouty polyarthralgia, asymptomatic hyperuricemia, and acute gouty arthritis.
• Any anti-TB drug may cause rash. If rash occurs, withhold all medications until rash subsides. Rechallenge drugs sequentially every 3 to 4 days to find cause. Usual sequence is INH, rifampin, PZA, EMB, using the first line (most important) drug first.
• Rifampin may cause pruritus with or without rash, GI adverse effects, flu-like symptoms, hepatotoxicity, rare severe immunologic reactions, orange discoloration of body fluids, and drug interactions with hormonal contraceptives, methadone, and warfarin.

Classification of Pulmonary Tuberculosis TB
An infectious disease caused by the tubercle bacillus, Mycobacterium tuberculosis. Often involves the lungs but may involve other parts of the body as well. Data from the history, physical examination, skin test, chest x-ray, and microbiologic studies are used to classify Pulmonary Tuberculosis TB into one of five classes. A classification scheme provides public health officials with a systematic way to monitor epidemiology and treatment of the disease (American Thoracic Society, 2000).

Classification of Pulmonary Tuberculosis TB

• Class 0: no exposure; no infection
• Class 1: exposure; no evidence of infection
• Class 2: latent infection; no disease (e.g. positive PPD reaction but no clinical evidence of active TB)
• Class 3: disease; clinically active
• Class 4: disease; not clinically active
• Class 5: suspected disease; diagnosis pending

Primary tuberculosis

This stage of infection, primary tuberculosis, is usually clinically and radio graphically silent. In most persons with intact cell-mediated immunity, T cells and macrophages surround the organisms in granulomas that limit their multiplication and spread. The infection is contained but not eradicated, since viable organisms may lie dormant within granulomas for years to decades.

Latent tuberculosis infection

Individuals with this latent tuberculosis infection do not have active disease and cannot transmit the organism to others. However, reactivation of disease may occur if the host’s immune defenses are impaired. Active tuberculosis will develop in approximately 10% of individuals with latent tuberculosis infection who are not given preventive therapy; half of these cases occur in the 2 years following primary infection. Up to 50% of HIV-infected patients will develop active tuberculosis within 2 years after infection with tuberculosis. Diverse conditions such as gastrectomy, silicosis, and diabetes mellitus and disorders associated with immunosuppression (e.g. HIV infection or therapy with corticosteroids or other immunosuppressive drugs) are associated with an increased risk of reactivation.

Progressive primary tuberculosis

In approximately 5% of cases, the immune response is inadequate and the host develops progressive primary tuberculosis, accompanied by both pulmonary and constitutional symptoms that are described below. Standard teaching has held that 90% of tuberculosis in adults represents activation of latent disease. New diagnostic technologies such as DNA fingerprinting suggest that as many as one-third of new cases of tuberculosis in urban populations are primary infections resulting from person-to-person transmission.

Pulmonary Tuberculosis Treatment

Antitubercular therapy with daily oral doses of isoniazid, rifampin, and pyrazinamide for at least 6 months usually cures Tuberculosis TB. After 2 to 4 weeks, the disease is no longer infectious and the patient can resume normal activities while continuing to take medication. A longer course of treatment may be necessary if the patient is slow to respond to treatment, require extended treatment for patients with AIDS

Treatment for Pulmonary Tuberculosis

• A combination of drugs to which the organisms are susceptible is given to destroy viable bacilli as rapidly as possible and to protect against the emergence of drug-resistant organisms.
• Current recommended regimen of uncomplicated, previously untreated Pulmonary Tuberculosis TB is an initial phase of 2 months of bactericidal drugs, including isoniazid (INH), rifampin (Rifadin), pyrazinamide (PZA), and ethambutol (EMB). This regimen should be followed until the results of drug susceptibility studies are available, unless there is little possibility of drug resistance.

1. If drug susceptibility results are known and organism is fully susceptible, EMB does not need to be included.
2. For children whose visual acuity cannot be monitored, EMB is not normally recommended except with increased likelihood of INH resistance or if the child has upper lobe infiltration and/or cavity formation Pulmonary Tuberculosis TB.
3. Due to increasing frequency of global streptomycin resistance, streptomycin is not considered interchangeable with EMB unless organism is known to be susceptible to streptomycin.
4. PZA may be withheld for severe liver disease, gout and possibly, pregnancy.
5. Adverse effects including liver injury have been noted with rifampin and pyrazinamide in a once daily or twice weekly combination, therefore this combination is not recommended for the treatment of latent Pulmonary Tuberculosis TB infection.

• Follow with 4 months of isoniazid and rifampin. Six months of therapy is usually effective for killing the three populations of bacilli: those rapidly dividing, those slowly dividing, and those only intermittently dividing.
• Sputum smears may be obtained every 2 weeks until they are negative; sputum cultures do not become negative for 3 to 5 months.
• Rifabutin (Mycobutin) is used as a substitute for rifampin if the organism is susceptible to rifabutin and for patients taking medications that may interact with rifampin.
• Second-line drugs, such as cycloserine (Seromycin), ethionamide (Trecator-SC), streptomycin, Amikacin (Amikin), kanamycin (Kantrex), capreomycin (Capastat),
  para-aminosalicylic acid, and some fluoroquinolones, are used in patients with resistance, for retreatment, and in those with intolerance to other agents. Patients taking these drugs should be monitored by health providers experienced in their use.
• For people suspected of having latent Pulmonary Tuberculosis TB infection (LTBI), treatment should begin after active TB has been ruled out.

Nursing Care Plans Pulmonary Tuberculosis TB

Common nursing diagnosis found in Nursing Care Plans Pulmonary Tuberculosis TB; Ineffective Airway Clearance, Risk for impaired Gas Exchange, Imbalanced Nutrition: Less than Body Requirements, Risk for Infection, Deficient Knowledge

Nursing Care Plans Pulmonary Tuberculosis TB

Nursing diagnosis ineffective Airway Clearance related to Thick, viscous, or bloody secretions Fatigue, poor cough effort Tracheal or pharyngeal edema

Nursing goal: Respiratory Status: Airway Patency

Nursing Intervention Nursing Care Plans Pulmonary Tuberculosis TB

Airway Management:

• Assess respiratory function, such as breath sounds, rate, rhythm, and depth, and use of accessory muscles. Rationale Diminished breath sounds may reflect Atelectasis. Rhonchi and wheezes indicate accumulation of secretions and inability to clear airways, which may lead to use of accessory muscles and increased work of breathing.
• Note ability to expectorate mucus and cough effectively; document character and amount of sputum and presence of Hemoptysis Rationale Expectoration may be difficult when secretions are very thick as a result of infection or inadequate hydration. Blood tinged or frankly bloody sputum results from tissue breakdown in the lungs and may require further evaluation and intervention
• Place client in semi- or high Fowler’s position. Assist client with coughing and deep-breathing exercises Rationale Positioning helps maximize lung expansion and decreases respiratory effort. Maximal ventilation may open Atelectasis areas and promote movement of secretions into larger airways for expectoration.
• Clear secretions from mouth and trachea, suction as necessary. Rationale Prevents obstruction and aspiration. Suctioning may be necessary if client is unable to expectorate secretions.
• Maintain fluid intake of at least 2,500 ML/day unless contraindicated Rationale High fluid intake helps thin secretions, making them easier to expectorate
• Humidify inspired oxygen Rationale Prevents drying of mucous membranes and helps thin secretions
• Administer medications, as indicated, for example: Mucolytic agents, such as acetylcysteine (Mucomyst) Rationale Reduces the thickness and stickiness of pulmonary secretions to facilitate clearance
• Bronchodilators, such as oxtriphylline (Choledyl) and theophylline (Theo-Dur) Rationale Increases lumen size of the tracheobronchial tree, thus decreasing resistance to airflow and improving oxygen delivery
• Corticosteroids (prednisone) Rationale May be useful in the presence of extensive involvement with profound hypoxemia and when inflammatory response is life-threatening
• Be prepared for and assist with emergency intubation Rationale Intubation may be necessary in rare cases of bronchogenic TB accompanied by laryngeal edema or acute pulmonary bleeding.

Evaluation (Expected Out Come) Nursing Care Plans Pulmonary Tuberculosis TB Nursing diagnosis ineffective Airway Clearance:

• Maintain patent airway.
• Expectorate secretions without assistance.
• Demonstrate behaviors to improve or maintain airway clearance.
• Participate in treatment regimen, within the level of ability and situation.
• Identify potential complications and initiate appropriate actions.

Complete Sample Nursing Care Plans Pulmonary Tuberculosis Tb

Patient Teaching Home Health Guidance for Patient with Pulmonary Tuberculosis

Patient teaching discharge and home healthcare guidelines for Patient with Pulmonary Tuberculosis. Be sure the patient understands all medications, including the dosage, route, action, and adverse effects. Instruct the patient to abstain from alcohol while on INH, and refer for eye examination after starting, then every month while taking, ethambutol. Teach the patient to recognize symptoms such as fever, difficulty breathing, hearing loss, and chest pain that should be reported to healthcare personnel.

Patient Teaching & Home Health Guidance for Patient with Pulmonary Tuberculosis

• Improve ventilation  by opening windows in room of affected person, and keeping bedroom door closed as much as possible.
• Instruct patient to cover mouth with fresh tissue when coughing or sneezing and to dispose of tissues promptly in plastic bags.
• Discuss Tuberculosis TB testing of people residing with patient.
• Investigate living conditions, availability of transportation, financial status, alcohol and drug abuse, and motivation, which may affect compliance with follow-up and treatment. Initiate referrals to a social worker for interventions in these areas.
• Report new cases of Tuberculosis TB to public health department for screening of close contacts and monitoring.
• Review possible complications: hemorrhage, pleurisy, symptoms of recurrence (persistent cough, fever, or Hemoptysis).
• Instruct patient on avoidance of job-related exposure to excessive amounts of silicone (working in foundry, rock quarry, sand blasting), which increases risk of reactivation.
• Encourage patient to report at specified intervals for bacteriologic (smear) examination of sputum to monitor therapeutic response and compliance.
• Instruct patient in basic hygiene practices and investigate living conditions. Crowded, poorly ventilated conditions contribute to development and spread of Tuberculosis TB.
• Encourage regular symptom screening and follow-up chest X-rays for rest of life to evaluate for recurrence.
• Show the patient and family how to perform postural drainage and chest percussion. Also teach the patient coughing and deep-breathing exercises. Instruct him to maintain each position for 10 minutes and then to perform percussion and cough.
• Instruct patient on prophylaxis with isoniazid for people infected with the tubercle bacillus without active disease to prevent disease from occurring, or to people at high risk of becoming infected.
• Educate asymptomatic people about PPD testing and treatment of latent Tuberculosis TB for positive results, based on risk grouping.

Breast cancer is a leading killer after lung cancer high incidence of age since the age of 30 years, Breast cancer is rarely found in the age below 20 years. It is most common after age 50. Early detection and treatment influences the prognosis considerably of Breast cancer. Complete history and physical examination should  be done in A woman with a new breast mass. The differential diagnosis of a breast mass can be broad, including malignancies such as primary breast cancer, lymphoma, or sarcoma, or benign breast lesions such as cysts, fibroadenoma, and fat necrosis. Even skin conditions, such as sebaceous cysts, abscesses, or thrombophlebitis may occur with a palpable mass. The history and physical will help aid in the diagnosis, but ultimately a biopsy is confirmatory of the diagnosis.

Causes for Breast Cancer

The origin of breast cancer is a complex interaction between the biologic and endocrine properties of the person and the environmental exposures that may precipitate mutation of cells to a malignancy. Despite known hereditary risk factors, the majority of breast cancers are diagnosed in women with no such risk factors. Although 10% to 20% of breast cancer patients have a family history suggestive of a hereditary susceptibility, only 5% of all breast cancers can be attributed to a known genetic defect

Risk factors for Breast Cancer:

• Family history of breast or ovarian cancer
• Age, The incidence of breast cancer increases with age and steadily after age 50. Thus, 75% of all cases of breast cancer are diagnosed in postmenopausal women Premenopausal
• Parity and lactation: long menstrual cycle, early onset of menses, late menopause. First pregnancy before age 20 or after age 31, The data on lactation are mixed but appear to indicate a decreased risk of breast cancer if women nurse for a long duration
• High-fat diet
• Endometrial or ovarian cancer
• Radiation exposure, Exposure to ionizing radiation, such as in nuclear explosions or medical therapeutics, does appear to increase the risk of breast cancer.
• Estrogen therapy
• Antihypertensive therapy
• Alcohol and tobacco, there is an irrefutable link between alcohol consumption and breast cancer risk. A pooled analysis of 322,647 women showed a positive linear relationship between incremental alcohol intake and increasing breast cancer risk.
• Breast disease, Benign breast disease, such as fibrocystic disease, do not increase the risk of breast cancer. Papillomas, sclerosing adenosis, and lobular carcinoma in situ are also known to increase the risk.

Complications for Breast Cancer

Metastasis leads to site-specific complications, bone, brain, and respiratory problems if it spreads to the lung.

Diagnostic tests Breast Cancer

• Screening and early detection:  Mammography, Breast examinations, High-risk patients
• Mammogram
• Ultrasound of the breast
• Biopsy

Treatment for Breast Cancer

Depends on the stage and type of Breast Cancer

• Stage I   size less 2 cm No node involvement, no metastasis
• Stage II Size Up to 5 cm May have axillary’s node involvement, no metastasis
• Stage III Varied (any size) Extended to skin or chest wall, nodes involved (immovable axillary node)
• Stage IV Varied Distant metastasis with ipsilateral supraclavicular nodes

Therapy may include a combination of surgery, radiation, chemotherapy, and hormone therapy

Surgical. The goal of surgery is control of cancer in the breast and the axillaries nodes

• Lumpectomy
• Partial mastectomy (also known as segmental mastectomy or quadrantectomy) removes one-quarter or more of the breast.
• Simple or total mastectomy is the removal of the breast but not the lymph nodes or pectoral muscles.
• Modified radical mastectomy is the removal of the breast and some of the axillary lymph nodes.
• Radical mastectomy is the removal of the breast, pectoralis major and minor, and axillary lymph nodes. The use of this surgery has declined.

Nursing diagnosis for breast cancer determine with data that we Collect in nursing assessment and result from Diagnostic tests for Breast Cancer

Nursing Assessment Nursing Care Plans for Breast Cancer

• Patient History. Assess the patient’s and family’s previous medical history of breast cancer or other Cancers.
• Palpation may identify a hard lump, mass, or thickening of breast tissue. Palpation of the cervical supraclavicular and axillary nodes may also disclose lumps or enlargement.
• Painless lump or mass in her breast or that she noticed a thickening of breast tissue
• Examine the axillary and supraclavicular areas for enlarged nodes. You may note the tumor is firm and immovable.
• Assess the patient for pain or tenderness at the tumor site.
• Inspect the breast skin for signs of advanced disease: the presence of inflammation, dimpling, orange peel effect, distended vessels, and nipple changes or ulceration

Diagnostic tests Breast Cancer

• Screening and early detection:  Mammography, Breast examinations, High-risk patients
• Mammogram
• Ultrasound of the breast
• Biopsy

Nursing diagnosis for breast cancer:

Common Nursing diagnosis found on Nursing Care Plans for Breast Cancer

• Acute pain
• Body image disturbance related to significance of loss of part or all of the breast
• Anxiety
• Fear
• Imbalanced nutrition: Less than body requirements
• Impaired physical mobility
• Impaired skin integrity
• Ineffective coping
• Ineffective role performance
• Risk for infection
• Risk for spiritual distress
• Bathing or hygiene self-care deficit
• Energy field disturbance

Nursing Care Plans for Breast Cancer

NCPNursing care plans for Breast Cancer. Common nursing diagnosis found in nursing care plan for patient with Breast Cancer: Acute pain, Body image disturbance related to significance of loss of part or all of the breast, Anxiety, Fear, Imbalanced nutrition: Less than body requirements, Impaired physical mobility, Impaired skin integrity, Ineffective coping, Ineffective role performance, Risk for infection,        Risk for spiritual distress, Bathing or hygiene self-care deficit, Energy field disturbance

Nursing outcomes Nursing Care Plans for Breast Cancer

Patient will:

• Communicate feelings of comfort and decreased pain.
• Express that she feels less anxious.
• Participate in her own care at the highest level possible within the limitations of her illness.
• Express positive feelings about self.
• Express increased sense of well-being.
• Use situational supports to reduce fear.
• Maintain adequate nutrition through oral intake or i.v. fluids.
• Maintain optimal muscle strength and joint range of motion.
• Patient’s surgical wounds will appear pink without signs or symptoms of complications.
• Demonstrate adequate coping behaviors.
• Recognize limitations imposed by her illness and will express feelings about these limitations.
• Free from signs and symptoms of infection.
• Express the importance of her own belief system and inner resources.

Nursing interventions Nursing Care Plans for Breast Cancer

• Nursing interventions Nursing diagnosis acute pain related to Surgical procedure; tissue trauma, interruption of nerves, dissection of muscles. 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: Comfort: Manipulation of the patient’s surroundings for promotion of optimal comfort
• Nursing interventions nursing diagnosis anxiety related to change of body image; scarring, loss of body part, sexual attractiveness extent of disease, impact on others; uncertainty of prognosis; denial of own mortality Situational crisis. Nursing Interventions:  Anxiety Reduction: Minimizing apprehension, dread, foreboding, or uneasiness related to an unidentified source or anticipated danger. Calming Technique: Reducing anxiety in patient experiencing acute distress
• Nursing interventions nursing diagnosis: impaired skin integrity related to surgical removal of skin and tissue; altered circulation, presence of edema, drainage; changes in skin elasticity, sensation; tissue destruction of radiation therapy. Nursing interventions:  Wound Care: Prevention of wound complications and promotion of wound healing. Incision Site Care: Cleansing, monitoring, and promotion of healing in a wound that is closed with sutures, clips, or staples. Pressure Ulcer Care: Facilitation of healing in pressure ulcers
• Nursing interventions Nursing diagnosis: impaired physical mobility related to neuromuscular impairment; pain, discomfort; edema formation.  Nursing Interventions:  Exercise Therapy: specify level: Use of active or passive body movement to maintain or restore flexibility; use of specific activity or exercise protocols to enhance or restore controlled body movement. Pain Management: Alleviation of pain or a reduction in pain to a level of comfort acceptable to the patient
• Nursing interventions nursing diagnosis: imbalanced nutrition: less than body requirements related to hyper metabolic state associated with cancer consequences of chemotherapy, radiation, surgery anorexia, gastric irritation, taste distortions, nausea emotional distress, fatigue, poorly controlled pain.  Nursing Interventions:  Nutrition Management: Assisting with or providing a balanced dietary intake of foods and fluids. Weight Gain Assistance: Facilitating gain of body weight Eating Disorders Management
• Nursing interventions nursing diagnosis risk for Infection related to Inadequate secondary defenses and immunosuppression such as bone marrow suppression dose-limiting side effect of both chemotherapy and radiation Malnutrition; chronic disease process Invasive procedure. 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

Patient Teaching and Home Healthcare Guidelines for Breast Cancer

Patient Teaching and Home Healthcare Guidelines for Breast Cancer. Clearly explain all procedures and treatments for patient with Breast Cancer. Inform the patient that she may experience phantom breast syndrome a tingling or pins and needles sensation in the area where the breast was removed. Females who have had breast cancer in one breast are at higher risk for cancer in the other breast or for recurrent cancer in the chest wall. For this reason, urge the patient to continue examining the other breast and to comply with recommended follow up treatment

Explain to the patient that she may have an incision drain or some type of suction to remove accumulated fluid, relieve tension on the suture line, and promote healing The patient can expect to return home with dressings and wound drains. Teach how to self-care wound drains, empty the drainage receptacle twice a day, record the amount on a flow sheet, and take this information along when keeping a doctor’s appointment. Teach the patient how to identified symptoms of infection report symptoms of infection or excess drainage on the dressing or the drainage device

Review pain treatment medication instructions for frequency and precautions. Show the mastectomy patient how to ease postoperative pain by lying on the affected side or by placing a hand or pillow on the incision. Point out where the incision will be. Inform the patient that after the operation, she will receive analgesics because pain relief encourages coughing and turning and promotes well-being. Explain that a small pillow placed under the arm anteriorly may provide comfort. Tell the patient that she may move about and get out of bed as soon as possible, usually as soon as the effects of the anesthetic subside or the first evening after surgery.

Teach precautions to prevent lymphedema after node dissection, to help prevent lymphedema, instructs the patient to exercise her hand and arm on the affected side regularly and to avoid activities that might allow infection of this hand or arm. Tell her that infection increases the risk of lymphedema.

• Request no blood pressure or blood samples from affected arm.
• Urge the patient to avoid activities that could injure her arm and hand on the side of her surgery. Caution her not to let blood be drawn from or allow injections into that arm. She should also refuse to have blood pressure taken or I.V. therapy administered on the affected arm.

FOLLOW UP:

• Prepare the patient and family for a variety of encounters with healthcare providers (radiologist, oncologist, and phlebotomist).
• Provide information of local community resources and support groups for emotional Support

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

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.

Nursing Diagnosis for Lung Cancer

To determine nursing diagnosis for Lung cancer, Nurses use Nursing assessment as tools for collecting data from the patients. Its included patient history, physical psychosocial assessment, and result from Diagnostic tests.

Nursing Assessment Nursing care Plans for Lung Cancer

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

1. Chest radiographs plain anterior-posterior and lateral views not reliable to find lung tumors in their earliest stage.
2. 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.
3. Spiral computed tomography of the chest.
4. Magnetic Resonance Imaging (MRI) 92% accuracy in the diagnosis of mediastinum invasion.
5. 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.
6. Bronchoscopic detection of tumor auto fluorescence could improve cure rates in selected groups at high-risk.
7. Sputum cytology
8. Percutaneous transthoracic needle biopsy
9. Fine needle aspiration or biopsy
10. Bronchoscopy.
11. Mediastinoscopy to evaluate lymph node involvement.
12. Scalene node biopsy (evaluate lymph node involvement)
13. 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).
14. 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

NCP Nursing care Plan for Lung Cancer. Common Nursing Diagnosis found in nursing care plan for 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

Nursing diagnosis 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:

1. 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.
2. 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.
3. 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.
4. 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.
5. 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:

1. 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).
2. Reposition frequently, placing client in sitting and supine to side positions. Rationale Maximizes lung expansion and drainage of secretions.
3. 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.
4. Encourage and assist with deep-breathing exercises and pursed lip breathing, as appropriate. Rationale Promotes maximal ventilation and oxygenation and reduces or prevents atelectasis.
5. 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.
6. Assist with and encourage use of incentive spirometer. Rationale Prevents or reduces atelectasis and promotes reexpansion of small airways.
7. 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:

1. 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.
2. 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.
3. 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

1. 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.
2. 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.
3. 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.
4. 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.
5. Encourage oral fluid intake, within cardiac tolerance. Rationale Adequate hydration aids in keeping secretions loose and enhances expectoration.
6. 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.
7. 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.
8. 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.
9. 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

1. 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.
2. 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.
3. 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.
4. 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.
5. Encourage verbalization of feelings about the pain. Rationale Fears and concerns can increase muscle tension and lower threshold of pain perception.
6. 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.
7. Schedule rest periods, provide quiet environment. Rationale Decreases fatigue and conserves energy, enhancing coping abilities.
8. 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.
9. 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:

1. 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.
2. 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.
3. 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.
4. 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.
5. 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.”
6. 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.
7. 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:

1. 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.
2. 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.
3. 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.
4. 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).
5. 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.
6. 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.
7. 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.
8. 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.
9. 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.
10. Recommend stopping any activity that causes undue fatigue or increased shortness of breath. Rationale Exhaustion aggravates respiratory insufficiency.
11. 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.
12. 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).
13. 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.
14. 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.
15. Shower in warm water, washing incision gently. Avoid tub baths until approved by physician. Rationale Keeps incision clean and promotes circulation and healing.
16. 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 for patient with Lung Cancer

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.

Patient Teaching, Discharge and Home Healthcare Guidelines for Lung Cancer

• 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.

Patient Teaching, Discharge and Home Healthcare Guidelines for Lung Cancer 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.

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

1. 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.
2. 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).
3. 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
4. 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.
5. Progression of disease: Single-agent Docetaxel, Gemcitabine, Paclitaxel
6. 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

1. Limited-stage disease;  Pulmonary resection stage I or stage II, Etoposide and Cisplatin and Radiation, Etoposide and Carboplatin
2. Extensive stage disease: Etoposide and Carboplatin +/− Paclitaxel, Adriamycin, Cyclophosphamide
3. 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

1. 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.
2. 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.

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

1. 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.
2. 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.
3. 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.
4. 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) : <5% of all lung cancers combined: Mesothelioma a rare tumor of the parietal pleura, Mesothelioma is another rare type of cancer which affects the covering of the lung (the pleura). It is often caused by exposure to asbestos, bronchial adenoma (carcinoid), fibrosarcoma.

Benign or malignant tumors may develop on the bladder. Bladder tumors can develop on the surface of the bladder wall (benign or malignant papillomas) or grow within the bladder wall (usually more virulent) and quickly invade underlying muscles.

Most bladder tumors are transitional cell carcinomas, arising from the transitional epithelium of mucous membranes. Less common are adenocarcinomas, epidermoid carcinomas, squamous cell carcinomas, sarcomas, tumors in bladder diverticula, and carcinoma in situ. Bladder tumors are most prevalent in men older than age 50 and are more common in densely populated industrial areas, but women are diagnosed at more advanced stages.

The most common presenting symptom of bladder cancer is hematuria. Gross hematuria obviously warrants a thorough evaluation of the genitourinary system. When gross hematuria is painless and total (present during the entirety of the urinary stream), it especially causes concern for bleeding from the bladder or upper tracts. Irritative urinary symptoms are relatively common at presentation, including frequency, urgency, and dysuria. The combination of these symptoms with hematuria is very suggestive and warrants full urologic evaluation. Depending on the location of their tumors, patients may have symptoms of bladder-outlet obstruction or ureteral obstruction. A small subset, 5% to 10% of patients, have symptoms related to metastatic disease.

Causes for Bladder cancer

Environmental carcinogens are known to predispose a person to transitional cell tumors such as 2-naphthylamine, benzidine, tobacco, coffee, and nitrates.Thus, workers in certain industries (rubber workers, weavers, leather finishers, aniline dye workers, hairdressers, petroleum workers, and spray painters) are at high risk for such tumors. The period between exposure to the carcinogen and development of symptoms is about 18 years.

Squamous cell carcinoma of the bladder is common in geographic areas where schistosomiasis is endemic, such as Egypt. What is more, it’s also associated with chronic bladder irritation and infection in people with renal calculi, indwelling urinary catheters, chemical cystitis caused by cyclophosphamide, and pelvic irradiation.

Complications of bladder cancer

If bladder cancer progresses, complications include bone metastases and problems resulting from tumor invasion of contiguous viscera.

Nursing diagnosis for Bladder Cancer determine from data that we collect from nursing assessment and from the test diagnostic results.

Nursing Assessment

The patient typically reports gross, painless, intermittent hematuria and often with clots. Patients may complain of suprapubic pain after voiding, and also complain of bladder irritability, urinary frequency, nocturia, and dribbling. If he reports flank pain, he may have an obstructed ureter.

Patient’s history

Gross, painless, intermittent hematuria is the most frequently reported symptom. Occult blood may be discovered during a routine urinalysis. Dysuria and urinary frequency are also reported. Burning and pain with urination are present only if there is infection. The patient may not seek medical attention until urinary hesitance, decrease in caliber of the stream, and flank pain occurs. Other symptoms may include suprapubic pain after voiding, bladder irritability, dribbling, and nocturia.

Physical assessment

The physical examination is usually normal. A bladder tumor becomes palpable only after extensive invasion into surrounding structures.

Psychosocial assessment

Diagnosis of cancer and treatment of cancer with radical cystectomy and creation of a urinary diversion system can threaten sexual functioning of both men and women. The procedure can cause impotence in men and psychological problems similar to those that accompany a hysterectomy and oophorectomy in women. In addition, a portion of the vagina may be removed, thus affecting intercourse. The psychological impact of a stoma and external urinary drainage system can cause changes in body image and libido.

Diagnostic tests for bladder cancer

To confirm a bladder cancer diagnosis, the patient typically undergoes

• Cystoscopy should be performed when hematuria first appears.
• Biopsy (If the test results show cancer cells, further studies will determine the cancer stage and treatment).
• Excretory urography can identify a large, early-stage tumor or an infiltrating tumor; delineate functional problems in the upper urinary tract; assess hydronephrosis; and detect rigid deformity of the bladder wall.
• Urinalysis can detect blood and malignant cells in the urine.
• Retrograde cystography evaluates bladder structure and integrity. Test results also help confirm a bladder cancer diagnosis. A bone scan can detect metastases. A computed tomography scan can define the thickness of the involved bladder wall and disclose enlarged retroperitoneal lymph nodes. Ultrasonography can find metastases in tissues beyond the bladder and can distinguish a bladder cyst from a bladder tumor.
• Laboratory tests, such as a complete blood count and chemistry profile, may be ordered to evaluate conditions such as anemia that are associated with bladder cancer.

Nursing diagnosis bladder cancer

Common nursing diagnosis found in nursing care plans for bladder cancer

• Acute pain
• Anxiety
• Disturbed body image
• Fear
• Impaired skin integrity
• Impaired urinary elimination
• Ineffective coping
• Ineffective therapeutic regimen management
• Risk for infection
• Sexual dysfunction

Nursing Care Plans for Bladder Cancer. Common nursing diagnosis found in nursing care plans for patient with Bladder cancer; Acute pain, Anxiety , Disturbed body image , Fear, Impaired skin integrity, Impaired urinary elimination, Ineffective coping, Ineffective therapeutic regimen management, Risk for infection, Sexual dysfunction.

Nursing Interventions Nursing Care Plans for bladder cancer

Nursing Diagnosis Acute Pain related to activity of disease process (cancer)

Nursing Outcomes Evaluation Criteria:

• Client will verbalize relief or control of pain.
• Client will appear relaxed and be able to sleep and rest appropriately.

Nursing Intervention nursing diagnosis Acute Pain related to activity of disease process (cancer):

1. Assess pain level, location, characteristics, and intensity Rationale Helps evaluate degree of discomfort and effectiveness of analgesia or may reveal developing complications. Pains in Surgical causes usually subside gradually as healing begins. Continued or increasing pain may be a sign of infection.
2. Listen to the patient’s fears and concerns. Stay with him during periods of severe stress and anxiety, and provide psychological support Rationale Reduction of anxiety and fear can promote relaxation and comfort.
3. Encourage and maintain bed rest during acute phase, if indicated Rationale Minimizes stimulation and promotes relaxation
4. Administer analgesics, as indicated Rationale Reduce or control pain and decrease stimulation of the sympathetic nervous system

Nursing Diagnosis Anxiety related to underlying Pathophysiology response, change in health status

Nursing Outcomes Evaluation Criteria:

• Patients will verbalize awareness of feelings of anxiety and healthy ways to deal with them.
• Patients will Report that anxiety is reduced to a manageable level.
• Patients will express concerns about effect of disease on lifestyle and position within family and society.
• Patients will demonstrate problem-solving skills and effective coping strategies and Use resources/support systems effectively.

Nursing Intervention Nursing Diagnosis Anxiety

1. Observe behavior indicative of anxiety which can be a clue to the client’s level of anxiety Rationale
2. Explain purpose of tests and procedures in bladder cancer treatment Rationale Reduces anxiety attributable to fear of unknown diagnosis and prognosis.
3. Encourage family and friends to treat client as before. Rationale Reassures client that role in the family and business has not been altered.
4. Administer sedatives and tranquilizers, as indicated. Rationale May be desired to help client relax until physically able to reestablish adequate coping strategies.
5. Review coping skills used in past and Identify coping skills the individual is using currently, such as anger, daydreaming, forgetfulness, eating, smoking, lack of problem solving. Rationale These may be useful for the moment, but may eventually interfere with resolution of current situation

Nursing Diagnosis Impaired urinary elimination

Nursing Outcomes Evaluation Criteria

• Patients will  Display continuous flow of urine, with output adequate for individual situation
• Patients will verbalize understanding of condition.
• Patients will achieve normal elimination pattern.
• Patients will demonstrate behaviors/techniques to prevent urinary infection.
• Manage care of urinary catheter, or stoma and appliance following urinary diversion.

Patient Teaching and Home Health Guidance for Bladder Cancer

Patient teaching, discharge and home healthcare guidelines for patient with Bladder Cancer. In early stages, bladders Cancer have no symptoms. Commonly, the first sign is gross, painless, intermittent hematuria. Patients with invasive lesions often have suprapubic pain after voiding. Other symptoms include bladder irritability, urinary frequency, nocturia, and dribbling. Provide complete information about disease, disease process and treatment. Provide complete preoperative teaching. Include an explanation of the operation the patient is to undergo. Discuss equipment and procedures that the patient can expect postoperatively. Teach the patient the specific procedure to catheterize the continent coetaneous pouch or reservoir.

Patient Teaching and Home Health Guidance for Bladder Cancer:

• Tell the patient what to expect from diagnostic tests. For example, make sure he understands that he may be anesthetized for cystoscopy.
• After the test results are known, explain the implications to the patient and his family.
• Demonstrate essential coughing and deep breathing exercises.
• In patient with orthotopic bladder replacement, teach the patient how to irrigate the Foley catheter. Suggest the use of a leg bag during the day and a Foley drainage bag at night. Once the pouch has healed and the Foley catheter, ureteral stents, and pelvic drain have been removed, teach the patient to “push” or “bear down” with each voiding.

Following creation of an ileal conduit, teach the patient how to care of the stoma and urinary drainage system:

• If needed, arrange for follow-up home nursing care or visits with an enterostomal therapist.
• Tell the patient that the ileal conduit stoma should reach its permanent size about 2 to 4 months after surgery.

• Teach the patient how to care for his urinary stoma. Instruction usually begins 4 to 6 days after surgery. Encourage appropriate relatives or other caregivers to attend the teaching session. Advise them beforehand that a negative reaction to the stoma can impede the patient’s adjustment.

• If the patient is to wear a urine collection pouch, teach him how to prepare and apply it. First, find out whether he will wear a reusable pouch or a disposable pouch. If he chooses a reusable pouch, he needs at least two to wear alternately.
• Teach the patient to select the right-sized pouch by measuring the stoma and choosing a pouch with an opening that leaves a (0.3 cm) margin of skin around the stoma.
• Instruct the patient to remeasure the stoma after he goes home in case the size changes.
• Tell the patient to empty the pouch every 2 to 3 hours or when it’s one-third full.
• Advise him to check the pouch frequently to ensure that the skin seal remains intact.
• Teach the patient to provide stoma care.
• To ensure a better seal and minimize skin breakdown, teach the patient how to use various products to level uneven abdominal surfaces, such as gullies, scars, and wedges.
• Postoperatively, tell the patient with a urinary stoma to avoid heavy lifting and contact sports. Encourage him to participate in his usual athletic and physical activities.

Nephrotic syndrome is a clinical disorder characterized by marked increase of protein in the urine (proteinuria), decrease in albumin in the blood (hypoalbuminemia), edema, and excess lipids in the blood (hyperlipidemia). These occur as a consequence of excessive leakage of plasma proteins into the urine because of increased permeability of the Glomerular capillary membrane.  Nephrotic syndrome essentials of Diagnosis: Edema, Hypertension, Hematuria with or without dysmorphic red cells, red blood cell casts. The Nephrotic syndrome is marked by massive proteinuria greater than 3.5 g/d, low levels of serum albumin, high levels of serum lipids, and pronounced edema. Acute onset of the disorder can occur in instances of circulatory disruption producing systemic shock that decrease the pressure and flow of blood to the kidney. Progression to the Nephrotic syndrome may also occur as a complication of the previously discussed forms of glomerulonephritis.

Causes of Nephrotic syndrome

About 75% of Nephrotic syndrome cases result from primary idiopathic glomerulonephritis. Classifications include the following:

• With minimal change disease (lipid nephrosis or nil disease) in children it’s the main cause of Nephrotic syndrome the glomeruli appear normal by light microscopy. Some tubules may contain increased lipid deposits.
• Membraneous glomerulonephritis the most common lesion in patients with adult idiopathic Nephrotic syndrome is characterized by uniform thickening of the Glomerular basement membrane containing dense deposits. It can eventually progress to renal failure.
• Focal glomerulosclerosis can develop spontaneously at any age, follow kidney transplantation, or result from heroin abuse.
• With membranoproliferative glomerulonephritis, slowly progressive lesions develop in the subendothelial region of the basement membrane. These lesions may follow infection, particularly streptococcal infection. This disease occurs primarily in children and young adults.

Other causes of Nephrotic syndrome include All of diseases that increase glomerular protein permeability, which leads to increased urinary excretion of protein, especially albumin, and subsequent hypoalbuminemia. Include metabolic diseases such as diabetes mellitus; collagen-vascular disorders, such as systemic lupus erythematosus and periarteritis nodosa; circulatory diseases, such as heart failure, sickle cell anemia, and renal vein thrombosis; nephrotoxins, such as mercury, gold, and bismuth; infections, such as tuberculosis and enteritis; allergic reactions; pregnancy; hereditary nephritis; and certain neoplastic diseases such as multiple myeloma.

Pathophysiology of Nephrotic syndrome

Increased permeability of the Glomerular membrane is attributed to damage to the membrane and changes in the electrical charges in the basal lamina and podocytes, producing a less tightly connected barrier. This facilitates the passage of high-molecular-weight proteins and lipids into the urine. Albumin is the primary protein depleted from the circulation.

The ensuing hypoalbuminemia appears to stimulate the increased production of lipids by the liver. The lower oncotic pressure in the capillaries resulting from the depletion of plasma albumin increases the loss of fluid into the interstitial spaces, which, accompanied by sodium retention, produces the edema. Depletion of immunoglobulin’s and coagulation factors places patients at an increased risk of infection and coagulation disorders. Tubular damage, in addition to Glomerular damage, occurs, and the Nephrotic syndrome may progress to chronic renal failure.

Clinical Manifestations of Nephrotic syndrome

The dominant Clinical Manifestations of Nephrotic syndrome is mild to severe dependent edema of the ankles or sacrum, or periorbital edema, especially in children. Such edema may lead to ascites, pleural effusion, weight gain, and high blood pressure.

• Insidious onset of pitting dependent edema, periorbital edema, and ascites, weight gain
• Fatigue, headache, malaise, irritability
• Marked proteinuria leading to depletion of body proteins
• Hyperlipidemia may lead to accelerated atherosclerosis

Complications of Nephrotic syndrome

Major complications include malnutrition, infection, coagulation disorders, and accelerated atherosclerosis. Thromboembolic complications renal vein thrombosis, venous and arterial thrombosis in extremities, pulmonary embolism, coronary artery thrombosis, cerebral artery thrombosis (especially in the lungs and legs). Hypovolemia. Hypochromic anemia can develop from excessive urinary excretion of transferrin. Opportunistic infections, hypertension, pleural effusion, and pericardial effusion may occur. Acute renal failure may occur. Altered drug metabolism due to decrease in plasma proteins. Progression to end stage renal failure

Nephrotic Syndrome Treatment

Nephrotic Syndrome Treatment. Correction of the underlying cause if possible is requires for effective treatment of Nephrotic syndrome. If it is caused by another disease, that underlying disease is treated. Supportive treatment consists of a nutritious, with restricted sodium intake, diuretics for edema, and antibiotics for infection. All nephrotoxins should be avoided. Some patients respond to an 8-week course of a corticosteroid such as prednisone followed by maintenance therapy. Others respond better to a combination of prednisone and azathioprine or cyclophosphamide. Treatment for hyperlipidemia frequently is unsuccessful. Immunosuppressant, antihypertensive, and diuretics can also help control symptoms. Angiotension converting enzyme inhibitors can decrease protein loss in urine. Some patients respond to a course of corticosteroid therapy, followed by a maintenance dose. Patients with chronic Nephrotic syndrome that’s unresponsive to therapy may require vitamin D replacement

Management of Nephrotic syndrome

• Treatment of causative Glomerular disease
• Diuretics (used cautiously) and angiotensin converting enzyme inhibitors to control proteinuria
• Corticosteroids or immunosuppressant agents to decrease proteinuria
• General management of edema:  Sodium and fluid restriction,  Infusion of salt-poor albumin,  Dietary protein supplements

• Low-saturated-fat diet
• If the kidneys lose their ability to function, dialysis may be necessary.

Special considerations in Nephrotic syndrome Treatment

• Frequently check urine protein levels.
• Measure blood pressure while the patient is in a supine position and also while he’s standing, be alert for a drop in blood pressure that exceeds 20 mm Hg.
• If the patient has had a kidney biopsy, watch for bleeding and shock.
• Monitor intake and output, and check weight at the same time each morning after the patient voids and before he eats and while he’s wearing the same kind of clothing.
• Ask the dietitian to plan a high protein, low sodium diet.
• Provide good skin care because the patient with Nephrotic syndrome usually has edema, if needed provide antiembolism stockings To avoid thrombophlebitis, encourage activity and exercise
• Offer the patient and family reassurance and support, especially during the acute phase, when edema is severe and the patient’s body image changes.

Nursing Diagnosis For Nephrotic syndrome

Nursing Diagnosis nursing care plans for Nephrotic syndrome determine with data that nurses collect in nursing assessment, and from result of diagnostic test

Nursing Assessment of Nephrotic syndrome

Patient’s history, Patients may report no illness before the onset of symptoms some patient have a history of systemic multisystem disease, such as lupus erythematosus, diabetes mellitus, amyloidosis, or multiple myeloma or have a history of an insect sting or venomous animal bite.The patient may complain of lethargy and depression. Your assessment may reveal two common problems: periorbital edema, which occurs primarily in the morning and is more common in children, and mild to severe dependent edema of the ankles or sacrum. Nurses should note orthostatic hypotension, ascites, and swollen external genitalia, signs of pleural effusion, anorexia, and pallor. Obtain history of onset of symptoms including changes in characteristics of urine and onset of edema.

Physical examination, Perform physical examination looking for evidence of edema and hypovolemic. Assess vital signs, daily weights, intake and output, and laboratory values. In later stages, inspect the patient for massive generalized edema of the scrotum, labia, and abdomen. Pitting edema is usually present in dependent areas. The patient’s skin appears extremely pale and fragile. You may note areas of skin erosion and breakdown. Often, urine output is decreased from normal and may appear characteristically dark, frothy, or opalescent. Some patients have hematuria as well.

Diagnostic Evaluation of Nephrotic syndrome

• Urinalysis marked proteinuria, microscopic hematuria, urinary casts, appears foamy
• 24-hour urine for protein (increased) and creatinine clearance (decreased)
• Protein electrophoresis and immunoelectrophoresis of the urine to categorize the proteinuria
• Needle biopsy of kidney for histological examination of renal tissue to confirm diagnosis
• Serum chemistry decreased total protein and albumin, normal or increased creatinine, increased triglycerides, and altered lipid profile

Nursing Diagnosis of Nephrotic syndrome

Common nursing diagnosis found in nursing care plans for patients with Nephrotic syndrome

• Imbalanced nutrition: Less than body requirements
• Disturbed body image
• Excess fluid volume
• Ineffective tissue perfusion: Renal
• Risk for injury
• Risk for Deficient Fluid Volume related to disease process
• Risk for Infection related to treatment with immunosuppressant

Nursing Care Plans for Nephrotic syndrome. Common Nursing diagnosis found in nursing care plans for patients with Nephrotic syndrome:  Imbalanced nutrition: Less than body requirements, Disturbed body image , Excess fluid volume, Ineffective tissue perfusion: Renal, Risk for injury Risk for Deficient Fluid Volume, Risk for Infection related to treatment with immunosuppressant

Nursing Interventions Nursing Care Plans

Nursing diagnosis Risk for Deficient Fluid Volume related to disease process

Desired Outcomes/Evaluation Criteria Client Will:

Hydration, Maintain adequate fluid balance as evidenced by vital signs and weight within client’s normal range, palpable peripheral pulses, moist mucous membranes, and good skin turgor.

Nursing Intervention nursing diagnosis Risk for Deficient Fluid Volume related to disease process:

Nursing Goal Increasing Circulating Volume and Decreasing Edema

1. Monitor daily weight, intake and output, and urine specific gravity. Rationale: Comparing actual and anticipated output may aid in evaluating presence and degree of renal stasis or impairment.
2. Monitor CVP (if indicated), vital signs, orthostatic blood pressure, and heart rate to detect hypovolemic. Rationale: Indicators of hydration and circulating volume and need for intervention.
3. Monitor serum BUN and creatinine to assess renal function. Rationale: Elevated BUN, Cr, and certain electrolytes indicate presence and degree of kidney dysfunction.
4. Administer diuretics or immunosuppressant as prescribed, and evaluate patient’s response. Rationale: May be used short-term to reduce tissue edema to facilitate movement of stone.
5. Infuse I.V. albumin as ordered. Rationale: NS is associated with significant protein loss. Serum albumin levels below 3.4 g/dL suggest need for IDPN infusions.
6. Encourage bed rest for a few days to help mobilize edema; however, some ambulation is necessary to reduce risk of Thromboembolic complications. Rationale: Edematous tissues are more prone to breakdown. Elevation promotes venous return, limiting venous stasis and edema formation.
7. Enforce mild to moderate sodium and fluid restriction if edema is severe; provide a high-protein diet. Rationale: As fluid is pulled from extracellular spaces, sodium may follow the shift, causing hyponatremia.

Nursing diagnosis Risk for Infection related to treatment with immunosuppressant

Desired Outcomes Evaluation Criteria Client Will: Immune Status, Experience no signs or symptoms of infection.

Nursing Intervention Nurse Care Plans for Nephrotic syndrome with nursing diagnosis Risk for Infection related to treatment with immunosuppressants:

Nursing Goal Preventing Infection

1. Monitor for signs and symptoms of infection. Rationale: Fever higher than 100.4°F (38.0°C) with increased pulse and respirations is typical of increased metabolic rate resulting from inflammatory process, although sepsis can occur without a febrile response.
2. Monitor temperature routinely; check laboratory values for neutropenia. Rationale: A shifting of the differential to the left is indicative of infection.
3. Use aseptic technique for all invasive procedures and strict hand washing by patient and all contacts; prevent contact by patient with persons who may transmit infection. Rationale: Reduces risk of cross-contamination.
4. Monitor effectiveness of antimicrobial therapy. Rationale: within 24 to 48 hours Signs of improvement in condition should occur.

Patient Teaching Discharge and Home Healthcare Guidelines

Patient Teaching Discharge and Home Healthcare Guidelines for patient with Nephrotic syndrome. The most common sign of Nephrotic syndrome is mild to severe edema of the ankles or sacrum, and periorbital edema, especially in children. Edema may lead to ascites, pleural effusion, weight gain, and high blood pressure. Accompanying signs and symptoms include orthostatic hypotension, lethargy, anorexia, depression, and pallor. Major complications are malnutrition, infection, coagulation disorders, Thromboembolic vascular occlusion, and accelerated atherosclerosis.

Patient Teaching Discharge and Home Health-care Guidelines for patient with Nephrotic syndrome:

• Teach the patient and family about the disease process, prognosis, and treatment plan for Nephrotic Syndrome.
• Teach the patient and family the purpose, dosage, route, desired effects, and side effects for all prescribed medications
• Explain that they need to monitor the urine daily for protein and keep a diary with the results of the tests.
• Have the patient or family demonstrate the testing techniques before discharge to demonstrate their ability to perform these monitoring tasks.
• Instruct the patient and family to avoid exposure to communicable diseases and to engage in scrupulous infection control measures (e.g. frequent hand washing).
• Encourage patients with hypercoagulability to maintain hydration and mobility and to follow the medication regimen. Inform patients on anticoagulant therapy of the need for laboratory monitoring of activated partial thromboplastin time or prothrombin time.
• Caution patients who are receiving steroid therapy to take the dosages exactly as prescribed, explain that skipping doses could be harmful or life-threatening. In cases of long-term steroid therapy, explain the signs of complications, such as GI bleeding, stunted growth (children), bone fractures, and immunosuppressant.
• If the patient is taking immunosuppressant, teach him and family members to report even mild signs of infection. If he’s undergoing long-term corticosteroid therapy, teach him and family members to report muscle weakness and mental changes, Caution patients who are receiving steroid therapy to take the dosages exactly as prescribed, explain that skipping doses could be harmful or life-threatening. In cases of long-term steroid therapy, explain the signs of complications, such as Gastrointestinal GI bleeding, stunted growth (children), bone fractures, and immunosuppressant.
• Suggest to the patient that he take steroids with an antacid or with cimetidine or ranitidine, to prevent Gastrointestinal GI complications, explain that the adverse effects of steroids subside when therapy stops, but warn the patient not to discontinue the drug abruptly or without a physician’s consent.
• Show the patient how to safely apply and remove anti-embolism stockings, If the physician prescribes anti-embolism stockings for home use.
• Stress the importance of adhering to the special diet or Ask the dietitian to plan a high-protein, low-sodium diet
• Encourage patients to resume normal activities as soon as possible.

Chronic renal failure CRF or end-stage renal disease, ESRD is a progressive deterioration of renal function, which ends fatally in uremia (an excess of urea and other nitrogenous wastes in the blood) and its complications unless dialysis or kidney transplantation is performed. Chronic renal failure, or ESRD, is a progressive, irreversible deterioration in renal function in which the body’s ability to maintain metabolic and fluid and electrolyte balance fails, resulting in uremia or azotemia (retention of urea and other nitrogenous wastes in the blood). Few symptoms develop until after more than 75% of Glomerular filtration is lost. Then, the remaining normal parenchyma deteriorates progressively and symptoms worsen as renal function decreases.

Pathophysiology of Chronic renal failure

End result of the gradual, progressive destruction of nephrons and decrease in Glomerular Filtration Rate (GFR), resulting in loss of kidney function that produces major changes in all body systems. Chronic kidney disease (CKD), although ultimately irreversible, may be slowed by improved standardized blood tests and availability of new drugs to control blood pressure

Stages of renal failure

Chronic kidney disease CKD stages correspond to the degree of nephron loss:

• Decreased renal reserve, Glomerular Filtration Rate GFR may be normal; slightly higher than normal, stage I: greater than or equal to 90 mL/min/1.73 m2; or somewhat less than normal, stage II: 60 to 89 mL/min/1.73 m2. Kidney dysfunction is present, however, it may be undiagnosed due to lack of symptoms blood urea nitrogen/creatinine (BUN/Cr) ratio is normal and nephron loss at less than 75%.
• Renal insufficiency, Nephron loss at 75% to 90%; GFR is moderately (stage III: 30 to 59 mL/min/1.73 m2) to severely (stage IV: 15 to 29 mL/min/1.73 m2) reduced. Slight elevation in BUN/Cr. Polyuria and nocturia present high output failure
• Renal Failure (GFR 20% to 25% of normal)
• End Stage Renal Disease (ESRD). Nephron loss at greater than 90% with a GFR of only 10% to 15% (stage V: less than 15 mL/min/1.73 m2). Fluid and electrolyte abnormalities, Azotemia and uremia present Dialysis required

Clinical Manifestations of Chronic renal failure

• Gastrointestinal GI anorexia, nausea, vomiting, hiccups, ulceration of   Gastrointestinal GI tract, and hemorrhage
• Cardiovascular hyperkalemic ECG changes, hypertension, pericarditis, pericardial effusion, pericardial tamponade
• Respiratory pulmonary edema, pleural effusions, pleural rub
• Neuromuscular fatigue, sleep disorders, headache, lethargy, muscular irritability, peripheral neuropathy, seizures, coma
• Metabolic and endocrine glucose intolerance, hyperlipidemia, sex hormone disturbances causing decreased libido, impotence, amenorrhea
• Fluid, electrolyte, acid base disturbances usually salt and water retention but may be sodium loss with dehydration, acidosis, hyperkalemia, hypermagnesemia, hypocalcemia
• Dermatologic pallor, hyperpigmentation, pruritus, ecchymoses, uremic frost
• Skeletal abnormalities renal osteodystrophy resulting in osteomalacia
• Hematologic anemia, defect in quality of platelets, increased bleeding tendencies
• Psychosocial functions personality and behavior changes, alteration in cognitive processes

Etiology Causes Renal Failure Chronic CRF

Multiple causes;

• Acute tubular necrosis (ATN) from unresolved acute renal failure (ARF)
• Chronic infections: glomerulonephritis, pyelonephritis, beta hemolytic streptococci infection
• Vascular diseases: hypertensive nephrosclerosis, renal artery stenosis, renal vein thrombosis, vasculitis
• Obstructive processes: long-standing renal calculi, Benign Prostatic Hyperplasia (BPH)
• Cystic disorders: polycystic or medullary kidney disease
• Collagen diseases: systemic lupus erythematosus (SLE) and collagen vascular disease
• Tumors: malignant (multiple myeloma) or benign
• Nephrotoxic agents: drugs, such as aminoglycosides, tetracyclines, contrast dyes, heavy metals
• Endocrine diseases: diabetes mellitus (DM), hyperparathyroidism
• Long-standing systemic hypertension

Such comorbidities as diabetes and hypertension are responsible for more than 70% of all cases of End Stage Renal Disease ESRD. Highest incidence of End Stage Renal Disease ESRD occurs in individuals older than age 65 years. over the last decade, there has been a 98% increase in incidence in those aged 75 years and older

Complications

If this condition continues unchecked, uremic toxins accumulate and produce potentially fatal physiologic changes in all major organ systems. Even in patient with life sustaining maintenance Renal dialysis or a kidney transplant, the patient may still have:

• Hyperkalemia due to decreased excretion, metabolic acidosis, catabolism, and excessive intake (diet, medications, fluids)
• Pericarditis, pericardial effusion, and pericardial tamponade due to retention of uremic waste products and inadequate dialysis
• Hypertension due to sodium and water retention and malfunction of the rennin angiotensin aldosterone system
• Anemia due to decreased erythropoietin production, decreased Red Blood Cell RBC life span, bleeding in the GI tract from irritating toxins, and blood loss during hemodialysis
• Bone disease and metastatic calcifications due to retention of phosphorus, low serum calcium levels, abnormal vitamin D metabolism, and elevated aluminum levels
• Peripheral neuropathy, Restless leg syndrome, one of the first symptoms of peripheral neuropathy, causes pain, burning, and itching in the legs and feet. Eventually, this condition progresses to paresthesia and motor nerve dysfunction unless dialysis is initiated
• Sexual dysfunction

Treatment Goal for Chronic renal failure CRF End Stage Renal Disease ESRD conservation of renal function as long as possible. Correct specific symptoms, minimize complications, and slow progression of the disease. Underlying conditions that cause chronic renal failure must be controlled.

Treatment For Chronic renal failure CRF End Stage Renal Disease ESRD

• Detection and treatment of reversible causes of renal failure (e.g. bring Diabetes Mellitus under control, treat hypertension)
• Dietary regulation low-protein diet supplemented with essential amino acids or their keto analogues to minimize uremic toxicity and to prevent wasting and malnutrition
• Fluid status maintaining fluid balance requires careful monitoring of vital signs, weight changes, and urine volume. Loop diuretics, such as furosemide only if some renal function remains, and fluid restriction can reduce fluid retention.
• A cardiac glycoside may be used to mobilize edema fluids; an antihypertensive, especially an angiotensin-converting enzyme inhibitor, to control blood pressure and associated edema.
• Treatment of associated conditions to improve renal dynamics
• Anemia recombinant human erythropoietin (Epo-gen), a synthetic hormone. Anemia necessitates iron and folate supplements; severe anemia requires infusion of fresh frozen packed cells or washed packed cells.
• Acidosis replacement of bicarbonate stores by infusion or oral administration of sodium bicarbonate
• Hyperkalemia restriction of dietary potassium; administration of cation exchange resin
• Phosphate retention decrease dietary phosphorus (chicken, milk, legumes, carbonated beverages); administer phosphate-binding agents because they bind phosphorus in the intestinal tract
• Drug therapy, surgery, and dialysis Maintenance renal dialysis or kidney transplantation when symptoms can no longer be controlled with conservative management. Antiemetic taken before meals may relieve nausea and vomiting, and cimetidine, omeprazole, or ranitidine may decrease gastric irritation. Methylcellulose or docusate can help prevent constipation.