Check Yourself #4
Cardiac/Oncology
While we may (un-) lovingly deride the NCLEX for its structure (the most correct answer, anyone?), it does do a good job of evaluating nursing judgement and showing what/how you should be thinking while nursing.
And it doesn’t stop with the NCLEX. Every certification exam you take is built on the same structure. Yay. So, let’s practice and check our knowledge at the same time.
A patient with a new diagnosis of small cell lung cancer reports feeling short of breath. The patient is tachypneic and auscultation reveals distant heart sounds. Distal pulses have changed from 2+ to 1+, and the patient’s blood pressure is 90/40 mm Hg. Which additional physical examination findings should the nurse expect?
A. Coarse breath sounds and pitting lower extremity edema
B. Bradycardia and cool, clammy extremities
C. Increasing jugular venous distention and clear lung sounds
D. Tachycardia and warm, flushed extremities
Source: Critical Care Nurse, Vol 42, Issue 4, June 2023
This one gave me pause. I don’t know much about the subtleties of the different forms cancer and how they affect the body. When I get a cancer patient, usually the cancer part of their illness isn’t the most pressing concern. I let the oncology team handle that part and I manage the ICU part. Hooray for interdisciplinary teams!
So, let’s look at the facts we’re given and work backwards. We have tachypnea and distant heart sounds. We are right at the edge of hypotension and pulses have diminished.
My first thought is heart failure. Blood is not moving around as it should, but is it from overload or obstruction? From my own clinical practice, I habitually would go with option A: coarse breath sounds and pitting lower extremity edema. (I see a lot of congestive heart failure patients. Like, so many.)
However, test questions generally don’t give you useless information. Lung cancer is mentioned specifically, as well as a particular type, so I need to keep that in mind. I have no reason to assume the patient has preexisting heart failure. Some other intrathoracic process is happening.
Lucky me, I’m sitting in my office and can crack open my textbooks. Small cell lung cancer is extremely aggressive and invades local structures, including the esophagus and mediastinum. It usually isn’t diagnosed until it is well advanced and metastasized.
With that in mind, I’m now leaning toward obstruction. Maybe it’s a tumor, maybe just fluid, but something is not letting the heart fill and compress as it should. With peripheral pulses reduced, blood is not getting through the heart and to the body. We’re looking at cardiac tamponade, a critical event that needs immediate intervention.
The patient surely isn’t bradycardic, not with something compressing the heart. The decreased stroke volume will cause tachycardia in order to keep up cardiac output. (SV x HR = CO). So that’s option B off the list.
Again, we’re down to two. So, which is more indictive of cardiac tamponade?
With a blood pressure of 90/40, I doubt the patient’s extremities are warm and flushed. In response to the decreased cardiac output, the peripheral vasculature would clamp down to force as much blood as possible to central circulation. Kidneys are way more important than fingers and toes, biologically speaking.
And, if I reach way back into nursing school, I can dredge up Beck’s Triad, which defines the signs of cardiac tamponade:
Hypotension with a narrowed pulse pressure
Jugular venous distention (JVD)
Muffled heart sounds
We’ve two of the three signs (90/40 is not really ‘narrowed’ in my opinion, I see that BP all the time. 90/70 would be weird, but I digress).
The answer is option C: Increasing jugular venous distention and clear lung sounds.
How’d you do? Questions? Confusion? Too easy? Comment and let me know if you have any sore spots you want to review.
References
Porth’s Pathophysiology: Concepts of Altered Health States (9th Edition). Grossman, S.C., Porth, C.M.
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Enjoy!
Anna, RN, BSN, CCRN
Necessary disclaimer: I am discussing medications and medical conditions in this article based on my personal experiences as a nurse. Your facility may have different requirements and resources. Use your own nursing judgement to assess and treat your patients according to your governing body and facility guidelines. All information within this article is correct to the best of my knowledge, but should be confirmed through verified evidence-based sources. I am not responsible for any clinical decisions made based on this article.