NU144 Unit 6 Oncologic Emergencies Case Study Example

A Swollen Face and a Sodium of 121: A Case Study Analysis of Superior Vena Cava Syndrome and Inappropriate Antidiuresis in a Composite 69-Year-Old Man With Newly Found Small Cell Lung Cancer, Where Circulation and Brain Chemistry Meet

[Student Name]

Purdue University Global

NU144: Medical-Surgical Nursing II

Unit 6 Case Study Analysis

[Instructor Name]

[Date]

The patient is composite; values are bracketed where illustrative, and oncology and medical teams direct treatment.

The Case

[Mr. T.], composite, 69, smoked for fifty years. His wife noticed his face looked puffy in the mornings for two weeks, and his shirt collars no longer fit. Today he was confused and unsteady. On arrival: face and neck swollen, veins across his upper chest visible and full, breathing [24] with mild breathlessness lying flat, saturation [93] percent. Blood pressure [138/82]. Sodium [121] mmol/L, serum osmolality low, urine concentrated with a high urine sodium. Scan: a large mass in the right upper chest compressing the superior vena cava. Biopsy later confirms small cell lung cancer.

Emergency One: Superior Vena Cava Syndrome

The superior vena cava returns blood from the head, neck and arms to the heart. When a tumor compresses it, blood backs up, causing swelling of the face, neck and arms, distended chest veins, headache and breathlessness, often worse lying down or bending forward. Collateral veins open slowly, which is why symptoms build over weeks. The most serious risks are airway narrowing from swelling and, rarely, brain swelling (Harding et al., 2023). Treatment depends on the cancer type: small cell tumors usually shrink quickly with chemotherapy, while a stent placed in the vein can relieve severe symptoms within days when needed.

Emergency Two: Inappropriate Antidiuresis

Small cell lung cancer cells can produce antidiuretic hormone without regard to the body's needs. The kidneys retain water, diluting the blood's sodium even though total body water is only modestly increased. The diagnosis rests on low serum sodium and osmolality with inappropriately concentrated urine in a patient who is not dehydrated and has normal kidney, thyroid and adrenal function (Ellison & Berl, 2007). Low sodium draws water into brain cells, causing confusion, unsteadiness and, if severe or rapid, seizures.

His confusion was not from the tumor in his brain or from low oxygen; it was water, held back by a hormone his cancer was making.

Ruling Out Other Causes of Confusion

Several causes had to be considered before his confusion was attributed to low sodium. Brain metastases are common in small cell lung cancer and could cause confusion and unsteadiness; a head scan was done and showed none. Low oxygen was unlikely with a saturation of [93] percent. High calcium, another cancer-related cause, was excluded with a normal calcium. Medications such as thiazide diuretics or certain antidepressants can cause low sodium, but he took neither. With those excluded, the low sodium explained his symptoms, and its correction confirmed it as his confusion cleared.

Why One Tumor Caused Both

The mass causes the first emergency by its size and position and the second by what its cells secrete. Recognizing the shared source matters, because treating the cancer, usually with chemotherapy for this type, addresses both.

Nursing Priorities

1. Airway and breathing: elevate the head of the bed to reduce facial swelling; watch for stridor, hoarseness or worsening breathlessness; avoid tight collars.

2. Neurological safety: seizure precautions, frequent checks of orientation, fall precautions given his unsteadiness (Potter et al., 2023).

3. Sodium correction: fluid restriction as ordered, often [800] to [1,000] mL a day, with strict intake and output. Sodium must rise slowly; a rise of more than about [8] to [10] mmol/L in the first 24 hours risks a serious brain injury from rapid shifts (Ellison & Berl, 2007). Sodium is checked every few hours as ordered.

4. Circulation in the arms: avoid IV lines and blood pressure cuffs in the right arm when possible, since venous return is obstructed.

5. Emotional support for a new cancer diagnosis delivered during an emergency.

Teaching and Support

He and his wife learned the diagnosis during the same admission, in the middle of two emergencies. The nurse helped them keep track of what was urgent and what could wait, explained the fluid restriction as part of treating his confusion rather than a punishment, and arranged for the oncology nurse to meet them before chemotherapy began. His wife was taught to recognize returning confusion, increasing swelling of his face or arms and new breathlessness, all reasons to call. Measuring his fluids with marked cups helped him follow the restriction without counting in his head.

Outcome

Over three days his sodium rose to [128] with fluid restriction, and his confusion cleared. Chemotherapy began on day four, and his facial swelling lessened over the following week. As the tumor shrank with treatment, his sodium continued to rise toward normal without further restriction, which fit a hormone source that was shrinking along with the mass. He went home on day nine with his wife, an oncology follow-up and written signs to report.

References

Ellison, D. H., & Berl, T. (2007). The syndrome of inappropriate antidiuresis. The New England Journal of Medicine, 356(20), 2064-2072. https://doi.org/10.1056/NEJMcp066837

Harding, M. M., Kwong, J., Hagler, D., & Reinisch, C. (2023). Lewis's medical-surgical nursing: Assessment and management of clinical problems (12th ed.). Elsevier.

Potter, P. A., Perry, A. G., Stockert, P. A., & Hall, A. M. (2023). Fundamentals of nursing (11th ed.). Elsevier.