Nursing Care Plan

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NursingCare Plan

NursingCare Plan

NANDA: Lung cancer as evidenced by shortness of breath.

NOC: Shortness of breath

Expected Client Outcomes:

  1. The desired outcome is to free the symptoms that are associated with respiratory distress.

  2. The patient will demonstrate efficient and normal breathing patterns.

NIC: Dyspnea Management

Nursing Interventions

1. Noting the rate and depth of respiration. The use of accessory muscles and changes in skin color are noted.

2. Auscultating the lungs for abnormal health sounds.

3. Nurses can monitor pulse oximetry readings and ABGs. They can also monitor the levels of Hemoglobin.

4. The patient should be encouraged to do deep-breathing exercises.

5. Assessing responsiveness of the patient to activities and encouraging rest periods.

Scientific Rationale

1. Respirations are increased due to compensatory mechanisms for the lung tissue that has had the abnormal growths (Matt Vera, 2014).

2. Lack of air movement is normal in pneumonectomy patient (Matt Vera, 2014).

3. A decreased partial oxygen and carbon dioxide will indicate need for ventilator supports (Matt Vera, 2014).

4. The exercises will promote maximum ventilation and oxygenation. It will also reduce and prevent atelectasis (Matt Vera, 2014).

5. An increased oxygen consumption will lead to dyspnea and changes in vital signs with activity (National Cancer Institute, 2015).

NANDA: Ineffective Airway Clearance in relation to Lung Cancer

NOC: Airway Clearance

Expected Client Outcomes:

  1. The patient airway should be demonstrated with fluid secretions that can beexpectorated, noise respirations.

  2. The patient should have clear breath sounds.

NIC: Improving Airway Clearance

Nursing Interventions

1. Auscultating the chest to check for breath sounds and if there are secretions.

2. Observing the amount and nature of sputum produced. It should be observed whether there is blood accompanying the sputum

3. Encouraging oral fluids and food intake. This should be done on a routine basis. At least 2500mL per day should be taken

4 Assessing if there is discomfort or pain and give medication before the breathing exercise.

5. Coughs should be checked if they are weak. The cough effort should be assessed if it clears breath sounds. Deep endotracheal suctioning should be avoided in pneumonectomy patients. The patient should be advised to start coughing and breathing as soon as possible

Scientific Rationale

1. Noisy respirations and wheezes will indicate airway obstruction and retained secretions (National Cancer Institute, 2015).

2 .A colorless sputum is normal while a thick and bloody sputum indicates secondary problems like local hemorrhage. It could also be an indication of pulmonary edema or pneumonia (Matt Vera, 2014).

3. This will keep the secretions loose and enhance expectoration (Matt Vera, 2014).

4. This will encourage the patient more deeply and effectively to lower incidences of respiratory insufficiency (National Cancer Institute, 2015).

5 Suctioning generally increases the risk of mucosal damage as well as hypoxemia. Deep endotracheal suctioning is contraindicated after pneumonectomy to reduce the chances of the bronchial stump suture line from rupturing. Suctioning should only be done to initiate effective coughing (Matt Vera, 2014).

NANDA Diagnosis: Acute pain in relation to Lung cancer

NOC: Acute Pain

Expected Client Outcomes

1. The patient should appear relaxed

2. The patient should participate in the desired activities

NIC: Pain Management

Nursing Interventions

1.Asking the patient about pain and classifying it on a 0-10 scale

2 Assessing the verbal and nonverbal pain cues on the patient

3. Scheduling rest periods and provision of a quiet environment.

4. Assist with self-care activities including breathing and arm exercises.

5. Evaluation of effectiveness of pain control. The patient should be given enough medication to control the pain

Scientific Rationale

1. This intervention assists in evaluating of pain that is related to cancer. The rate scale assesses the level of pain and gives a tool for determining the effectiveness of analgesics (Matt Vera, 2014).

2. This will give information about the degree of pain that the patient experiences and the need for an intervention (Matt Vera, 2014).

3. This intervention decreases fatigue and conserves energy (National Cancer Institute, 2015).

4. Physical assistance will be required before the patients becomes confident to perform the activities due to the fear of pain (National Cancer Institute, 2015).

5. Pain management is left to the discretion of the patient because pain perception and relief are subjective situations. The nurse should observe nonverbal cues for pain in case the patient is not able to provide input (Matt Vera, 2014).

References

Lehto,R. H. (2014). Lung cancer screening guidelines. The nurse’s role inpatient education and advocacy. Clin. J. Oncol. Nurs, 18(3), 338-342.http://www.ncbi.nlm.nih.gov/pubmed/24867114

MattVera, R. (2014). 5 Lung Cancer s – Nurseslabs.Nurseslabs. Retrieved 25 March 2016, fromhttp://nurseslabs.com/5-lung-cancer-nursing-care-plans/

NationalCancer Institute. (2015). “Cancer Fact Sheet.” Accessed on March17, 2016, http://seer.cancer.gov/statfacts/html/lungb.html