Roosevelt College System Institute of Nursing and Health Education Cainta, Rizal

A Case Presentation For Lung Cancer

Submitted By: Paulo Borjal Glenen Cabrejas Nikki Monica Caganan Allan Maglente Catherine Totaan

Submitted To: Mrs. Grace G. Magno RN MAN Date Submitted: February

INTRODUCTION

BIOGRAPHICAL DATA Name: Pt. CA Address: Lot 60 Cluster E. Bagong Nayon 1, Antipolo City Gender: Male Birth date: January 29, 1950 Religion: Roman Catholic Attending Physician: Dr. San Juan Date of Admission: January 30, 2011 Admission Diagnosis: Lung Cancer Stage 3 Present Complaint: Loss Bowel Movement and Difficulty of Breathing Time: 1:00 PM Room No.: 409-PC Age: 61 Birthplace: Daet Camarines Norte

IPPA
1. Assessment General Appearance 1.1 Body Built 1.2 Posture 1.3 Gait Normal Findings 1.1 big frame 1.2 upright 1.3 smooth rhythmic Analysis

Posture is upright when the clients appears to comfortable and attentive. (weber pg.113) The person appears clean and groomed appropriately for her age, occupation and socio economic group. (physical examination Jarvis pg.182) Vital signs provide data that reflects the status of several body system including, not limited to the cardiovascular, neurological, peripheral vascular & respiratory system. Pallor is seen in arterial insufficiency, decreased blood supply and anemia. Pallid tones vary from pale to ashen without underlying pink. The skin of an aging was loses its elasticity, it folds and sags; it looks parchment thin, dry and wrinkled. (Physical Examination and Health Assessment 3rd edition by Carolyn Jarvis p. 216) The nail plate is clear with fine longitunal ridges that become prominent in aging. Nails take their pink color from the underlying nail bed of highly vascular epithelial cells. The lunula is the white opaque semi lunar area at the proximal end of the nail. The cuticle works like a gasket to cover and protect the nail matrix, the nail matrix is lies over the nail. (Physical Examination and Health Assessment 3rd edition by Carolyn Jarvis p. 215)

1.4 Dress, Grooming Hygiene 1.5 Odor (Body/Breath) 1.6 Obvious Physical deformity 1.7 Vital Signs

1.4 appropriately dresses 1.5 None 1.6 None

1.7 Respiratory Rate: 26 Blood Pressure: 110/80 Pulse Rate: 89 Temperature: 37.9

2.

Skin 2.1 Color

2.1 Pale skin color

2.2 2.3 2.4 2.5 2.6 3.

Temperature Moisture Texture Turgor Hair Distribution

2.2 Warm 2.3 Dry 2.4 Rough 2.5 2.6 evenly Distributed

Nails 3.1 Nail Plate Shape 3.2 Nail Condition 3.3 Nail Bed Color

3.1 Convex 160 3.2 Smooth 3.3 Pale

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Head and Face 4.1 Skull 4.2 Scalp 4.3 Hair Condition 4.4 Face

4.1 Proportionate to body size 4.2 Tenderness 4.3 Evenly Distributed 4.4Symmetrical

The facial bones and orbits appear more prominent, and the facial skin sag owing to decreased elasticity, decreased subcutaneous fat, and decreased moisture in the skin. The lower face may look smaller and the teeth have been lost. (Physical Examination and Health rd Assessment 3 edition by Carolyn Jarvis p. 273) An aging person may have pendulous earlobes with a linea wrinkling because of loss of elasticity of the pinna. The ears are of equal size bilaterally with swelling or thickening. The skin is consistent with the person s facial skin color. The nasal hair grow coarser and stiffer and may not filter the air as well. The hairs protrude and may cause itching and sneezing. The oral cavity, the soft tissues atrophy and the epithelium thins, especially in the cheek and tongue. This result of taste buds, the impairment of taste includes a decrease in salivary secretion that is needed to dissolve flavoring agents. Many dental changes occur with an aging. The tooth surface is abraded. The gums begin to recede and the teeth begin erode at the gum line. The tooth loss occurs, the remaining teeth drift, causing malocclusion. The neck may show an increased cervical concave when the head and the jaw are extended forward to compensate for kyphosis at the supine. The aging person perform the ROM slowly; and they may experience dizziness with side movements.(Physical Examination rd and Health Assessment 3 edition by Carolyn Jarvis p. 287)

5.

Ears 5.1 Auricle 5.2 Pinna 5.3 External Canal 5.4 Hearing Acuity

5.1 Normal Racial Tone, Symmetric in size and Elastic 5.2 Recoils when folded 5.3 Some Cerumen 5.4 Respond to normal voice

6.

Nose 6.1 External

6.1 Normal Racial tone

7.

Mouth 7.1 Lips 7.2 Mucosa 7.3 Tongue 7.4 Teeth 7.5 Gums

7.1 Pallor 7.2 pallor 7.3 Midline, Rough and Pallor 7.4 complete 7.5 Pallor

8.

Neck 8.1 Neck Muscle 8.2 Lymph Nodes

8.1 he can move freely 8.2lymph node is not palpable

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Breast and Axilla 9.1 Symmetry 9.2 Contour

9.1 Symmetry 9.2 Flat

On expectations, the breast looks pendulous, flattened, and sagging. Nipples maybe retracted but can be pulled outward. (Physical Examination and Health Assessment 3rd edition by Carolyn Jarvis p. 436) Can indicate a number of health problems, most of which are related to the respiratory system. Gradual onset of dyspnea is usually indicative of lung changes such as emphysema, whereas sudden onset is associated with viral or bacterial infections. May indicate pneumonia, pulmonary edema, and pulmonary fibrosis. Velero rales of pulmonary fibrosis are heard louder and closer to stethoscope.

10. Chest and Lungs 10.1Breathing Pattern 10.2Breath Sounds

10.1 Tachypnea 10.2 Crackles coarse

11. Abdomen 11.1Skin Integrity 11.2Contour and Symmetry 11.3Bowel Sounds 12. Genitalia 12.1Pubic Hair 12.2Penis 12.3Urinary Meatus 12.4Scrotum 12.5Testes 12.6Inguinal Hernia

NOT INSPECTED

NOT INSPECTED