Question

J.H. is a 52-year-old white man who comes to the emergency department complaining of shortness of breath. He has not seen a health care provider for many years.

Subjective Data

• Has a 38 pack-year history of cigarette smoking

• States he has always been slender but has had 25-lb weight loss despite a normal appetite in the past few months

• Admits to a “smoker's cough” for the past 2 to 3 years; recently coughing up blood

• Is married and the father of three adult children

Objective Data

Physical Examination

• Thin, pale man looking older than stated age

• Height 6 ft; weight 135?lb (61.2?kg)

• Intermittently confused and anxious with rapid shallow respirations

• Vital signs: temperature 102.6° F (39.2° C), heart rate 120, respiratory rate 36

• Chest wall has limited excursion on right side; auscultation of left side reveals coarse crackles but clear with cough; right side has diminished breath sounds

Diagnostic Studies

• Arterial blood gases: pH 7.21, PaO2 58?mm?Hg, PaCO2 82?mm?Hg, HCO3? 33?mEq/L, O2 saturation 84%

• Chest x-ray: consolidation of the right lung, especially in the base with possible mass in the area of right bronchus; pleural effusion on the right side

• Bronchoscopy with biopsy of mass: small cell lung carcinoma

Collaborative Care

• Diagnosis: pneumonia with small cell lung cancer

• Follow-up with patient and family to consider treatment options

Discussion Questions

1. How would you classify J.H.'s pneumonia? Why is this important?

2. What is your analysis of J.H.'s arterial blood gas results?

3. Priority Decision: Based on the assessment data presented, what are the priority nursing diagnoses? Are there any collaborative problems?

4. Priority Decision: What are the priority nursing interventions for J.H.?

5. Delegation Decision: Identify activities that can be delegated to unlicensed assistive personnel (UAP).

6. You are planning a meeting with J.H. and his family to discuss their needs. The physician tells you that J.H. is terminally ill. Who will you include in this meeting?

7. Evidence-Based Practice: J.H.'s children tell you that they are worried they will get lung cancer, since their father has it and they grew up around his secondhand smoke. They want to know what kind of screening is available for them. How will you respond?

8. What is the goal if radiation therapy is used for J.H.?

9. What issues should be addressed in your teaching of J.H. and his wife as you prepare him for discharge and care at home?

Answer 1

1. Classification of pneumonia: J.H has Lobar Pneumonia associated with Chemical Pneumonia, as in lobar pneumonia only a single lobe, section of a lung is affected and in chemical pneumonia chemical toxicants are the main cause of pneumonia. In J.H's case he is smoker and due to toxic elements from smoking he suffer from chemical pneumonia and also in his subjective and objective data findings show that only one side of lung i.e right lobe is affected. Thus, J.H has lobar pneumonia associated with chemical pneumonia.

It is important to classify the pneumonia for the better treatment plan to the patient and by finding and treating the main causative reasons of the disease, it will be easy to treat the person and it also helpful in better prognosis.

2. ANALYSIS OF ARTERIAL BLOOD GASES: From the results of Arterial Blood Gases following implications are made:-

• Patient has RESPIRATORY ACIDOSIS, as pH is decreased and Pco₂ is increased.
• Patient suffer from Hypoventilation with Hypoxia, thus he has deep rapid respirations due to compensatory action by the lungs.

3. PRIORITY NURSING DIAGNOSIS: Accoring to the given data and condition of the patient the priority nursing diagnosis is TO MAINTAIN PATENT AIRWAY AND TO IMPROVE THE BREATHING PATTERN OF THE PATIENT.

COLLABORATIVE PROBLEMS: Patient has fever (102.6° F), due to increased infection. So the diagnosis will be TO DECREASE THE ELEVATED BODY TEMPERATURE DUE TO INFECTION.

TO MAINTAIN THE OXYGEN SATURATION OF PATIENT.

TO ASSESS THE AMOUNT OF BLOOD IN SPUTUM so as to prevent the frequent blood loss.

4. PRIORITY NURSING INTERVENTIONS : they based on the priority nursing diagnosis i.e. TO MAINTAIN PATENT AIRWAY AND TO IMPROVE THE BREATHING PATTERN OF THE PATIENT.

INTERVENTIONS:

• Provide Patient with Fowler or semi- fowler position.
• Make airway patent by doing suctioning due to secretions and cough.
• Encourage the patient to cough and to expell the secretions.
• Provide oxygen and steam inhalation.
• Provide chest physiotherapy to patient and encourage for spirometery.

5. DELECATED ACTIVITIES OF UNLICENSED ASSISTIVE PERSONNEL:

• Assist the client in Daily Living Activities such as hygiene, grooming, bathing etc.
• Recording and reporting of vital signs, height and weight.
• Measuring and recording intake and output of patient.
• Providing pain relieving interventions to the patient such as maintaining conducive environment.
• Observation and reporting of the changes in the current condition of the patient and respond to treatment.
• Providing therapeutic care to patient such as medication at right time.

6. While discussing the treatment plan and goals of J.H treatment the patient itself J.H, his wife and his children must be involved in the discussion as it is the collaborative decision of the family regarding treatment of a person.

7. As J.H's children are in contact with second hand smoke so they are in risk of developing the disease. So, it is the responsibility of the health care provider to educate the family regarding the screening tests for early diagnosis and treatment. The following screening tests should be advised:

• Chest X-ray.
• Blood investigations to diagnose any infection.
• ABG
• Sputum examination for blood.

8. GOAL DURING RADIATION THERAPY:

• Instruct the patient about the side effects of the therapy.
• Educate regarding the skin changes and urination changes during radiation therapy.
• Instruct the patient to drink more water as radiations may cause dehydration.
• Mark the area before giving radiation to provide better treatment.
• Apply moisturiser to the skin as radiations causes skin to dry.
• Avoid clothing that causes friction and rubbing to the skin.
• Protect the area from direct sunlight.

9. HEALTH TEACHING DURING DISCHARGE: During discharge following health education should provide to J.H and his wife:

• Provide Ventilated environment to the patient.
• Provide steam inhalation and chest physiotherapy.
• Do light exercise daily and take short walks.
• Drink plenty of water and take small and frequent meals.
• Instruct about appetite changes and side effects of treatment.
• Prepare the client for hair loss during therapy.
• Consult the physician in case any emergency occur.
• Regular follow-ups and treatment.