Metastatic Lung Adenocarcinoma: Building Maya’s Nursing Care Plan
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Maya’s story did not end when the scan results came back.
Maya is 29 and in the second year of her nursing degree. Investigations have confirmed lung adenocarcinoma with regional lymph-node involvement and a solitary brain metastasis. Suddenly, the language she has been learning at university is being used to describe her own body.
This continuation follows Maya beyond diagnosis and into nursing care. It is a worked educational example designed to show how assessment becomes a care plan, how priorities change over time and why the person behind the diagnosis must remain at the centre of every decision.
Start with Maya, not the diagnosis
Lung adenocarcinoma is a subtype of non-small-cell lung cancer. A biopsy tells the team what the tumour is, but it does not tell them everything they need to know about how Maya should be treated. Imaging, nodal assessment, metastatic investigations, pathology, molecular testing, biomarkers such as PD-L1 where appropriate, performance status, symptoms, comorbidities and Maya’s own preferences all contribute to treatment planning.
TNM staging separates information about the primary tumour (T), regional lymph nodes (N) and distant metastasis (M). Maya’s brain lesion represents distant metastatic disease, but a student should not invent a complete T or N category from information the scenario has not provided. Formal staging and treatment planning belong to the specialist multidisciplinary team.
At the start of ongoing care, Maya is alert and orientated and her observations are stable. She remains intermittently breathless on exertion, has a persistent cough and describes fatigue that is beginning to affect ordinary activities and university attendance. She has also experienced headaches associated with the brain metastasis.
Then she says something that changes the focus of the conversation: “Everyone keeps asking me about treatment. I keep thinking about university. My friends are going back on placement and I don’t even know if I’m still going to become a nurse.”
This is where care planning becomes more than writing a list of problems. Respiratory and neurological safety matter, but so do fatigue, nutrition, treatment burden, psychological wellbeing, fertility and sexual health where relevant, relationships, finances, education and Maya’s sense of who she is.
Building the care plan
Before reading the worked priorities, think through Maya’s situation as you would on placement. What could become immediately dangerous? What neurological changes would require urgent escalation? Which symptoms are limiting her day-to-day life? What does she need to understand before treatment decisions are made? And what has cancer changed outside her physical health?
Priority 1: Respiratory symptoms and deterioration
Assessed need: Maya has persistent cough and exertional breathlessness in the context of a primary lung malignancy. Her respiratory status needs ongoing assessment because deterioration could relate to the tumour, infection, pleural complications, pulmonary embolism, treatment toxicity or another cause.
What tells us this matters: she has confirmed lung adenocarcinoma, persistent cough, exertional breathlessness and reduced activity tolerance.
Agreed outcome: Maya’s respiratory symptoms will be assessed against her usual baseline, distressing symptoms will be managed within the agreed clinical plan and acute deterioration will be recognised and escalated promptly.
Nursing care and rationale: Assess respiratory rate, oxygen saturation, work of breathing, cough, sputum where present, chest discomfort and functional tolerance according to the clinical setting. A normal-looking saturation does not tell you how breathless Maya feels or what exertion now costs her. Ask what breathlessness stops her doing. Administer prescribed symptom-control treatment and oxygen only when clinically indicated and authorised within the relevant framework; oxygen treats hypoxaemia, not every sensation of breathlessness. Support positioning, pacing and energy conservation where appropriate.
New or rapidly worsening breathlessness, hypoxaemia, haemoptysis, pleuritic chest pain, syncope, fever or another acute change needs escalation. Known lung cancer must not become an explanation for every new respiratory symptom. Cancer also increases the risk of venous thromboembolism, so pulmonary embolism remains an important differential when the clinical picture changes.
Evaluation: Compare symptoms, observations and activity tolerance over time. Record what Maya can actually do as well as the physiological numbers.
Priority 2: Neurological safety
Assessed need: Maya has a known solitary brain metastasis and headaches. Nursing assessment therefore needs to recognise neurological change that could indicate complications such as cerebral oedema, seizure activity or focal neurological deterioration.
Agreed outcome: Maya will remain neurologically stable, understand which symptoms need urgent help and receive prompt assessment if new or worsening neurological features develop.
Nursing care and rationale: Establish Maya’s neurological baseline and assess cognition, speech, pupils, limb movement and sensation when clinically indicated and within competence. Ask about changes in headache pattern, nausea or vomiting, visual disturbance, weakness, altered sensation, balance, speech, seizures and changes in behaviour or cognition. A first seizure, prolonged or recurrent seizure, new focal deficit, reduced consciousness, rapidly worsening headache, repeated vomiting or another acute neurological deterioration requires immediate escalation.
Administer prescribed corticosteroids, anticonvulsants, analgesia and other medicines safely and monitor their effects. Do not assume every person with a brain metastasis should receive prophylactic anticonvulsants. Most importantly, Maya’s nursing knowledge does not replace individual safety-netting: she still needs to know exactly who to contact and when.
Evaluation: Compare findings with Maya’s documented baseline. Stable routine observations do not cancel out a new focal neurological symptom or seizure.
Priority 3: Treatment planning and informed participation
Assessed need: Maya is entering a complex period of specialist treatment planning. Because adenocarcinoma may undergo molecular and biomarker testing that influences systemic treatment, she needs information based on her actual tumour rather than generic assumptions about “metastatic lung cancer”.
Agreed outcome: Maya will understand the decisions currently being made, be able to identify the questions that matter to her and participate in treatment decisions to the extent she wishes.
Nursing care and rationale: Begin by asking what Maya has already been told and what she wants explained today. Do not assume that a student nurse wants, or can absorb, professional-level detail while receiving life-changing news. Reinforce information given by the specialist team within the nursing role and refer questions about prognosis, treatment selection or sequencing to the appropriate clinician. Check understanding conversationally rather than testing her medical knowledge.
Assess pain, nausea, fatigue, sleep, appetite, bowel function and other symptom-control needs and communicate them to the team. Where treatment may affect fertility, reproductive-health implications should be considered by the appropriate specialist team when relevant to Maya’s wishes and treatment urgency. Do not assume whether future fertility matters to her. Ensure she has contact details for her lung cancer clinical nurse specialist and knows how to obtain urgent advice.
Evaluation: Success is not Maya repeating oncology terminology. It is Maya understanding what she needs for the decisions in front of her and feeling able to ask for information to be repeated, simplified or paused.
Priority 4: Fatigue, nutrition and function
Assessed need: Maya’s fatigue and reduced activity tolerance are affecting everyday life. Cancer may contribute, but so can emotional distress, sleep disruption, reduced intake, anaemia, medicines and treatment. Fatigue should therefore be assessed rather than dismissed as inevitable.
Agreed outcome: Maya will receive individualised support to maintain nutrition, activity, rest and independence as far as possible, while potentially reversible contributors are identified and addressed by the appropriate team.
Nursing care and rationale: Explore the severity, pattern and functional impact of fatigue: personal care, walking, concentration, sleep, university work and social activity. Complete appropriate nutritional screening and monitor weight, appetite and intake where indicated, with dietetic referral when assessment identifies a need. Support a realistic balance of activity and rest rather than either prolonged inactivity or unrealistic goals. Pain, nausea, constipation, low mood and sleep problems may all worsen intake or energy and should be assessed rather than considered separate from the fatigue problem.
Evaluation: Use goals that mean something to Maya. Being able to shower independently, attend an appointment without becoming exhausted or concentrate long enough to answer university correspondence may tell you more than a generic statement that fatigue is “improved”.
Priority 5: Psychological wellbeing, university and identity
Assessed need: Cancer has disrupted the roles through which Maya understood herself. She has moved abruptly from learning to care for patients to becoming a patient while the course and cohort she expected to progress with continue without her.
Agreed outcome: Maya will remain central to decisions about her life as well as her treatment. She will have opportunities to identify what she fears losing, what matters most to her and what practical support she wants.
Nursing care and rationale: Ask what the diagnosis has changed for her rather than reducing psychological assessment to “Are you anxious?”. If she wants to discuss university, explore what nursing represents to her and what she is worried about: placement hours, progression, separation from her cohort, finances, confidence about returning to clinical environments or the fear that illness has taken away the future she expected.
With Maya’s agreement, help her reach appropriate university services such as her programme team, student support, disability or inclusion services and occupational health where relevant. Healthcare staff should not make academic decisions on the university’s behalf. Signpost welfare or financial support where illness affects income or study funding. Offer access to the clinical nurse specialist, psychological or psycho-oncology services, counselling or peer support according to Maya’s preferences and local provision.
Ask who she wants involved in conversations. Discuss body image, sexuality, fertility, relationships and treatment-related appearance changes sensitively when relevant rather than deciding which concerns a 29-year-old “should” have.
Maya’s clinical knowledge creates an unusual burden. Words such as metastasis may carry meaning before a clinician has finished the sentence. Ask whether that knowledge is helping, overwhelming her or both. Do not turn her into an informal member of her own healthcare team. She should not be expected to interpret her results, monitor herself clinically or reassure relatives because she is a student nurse.
Evaluation: There is no credible end-of-shift outcome in which Maya has “accepted” metastatic cancer. Instead ask whether distress has been recognised, practical support has begun where she wants it, questions have reached the right people and she still has agency in decisions.
The student nurse who became the patient
This part of Maya’s care deserves particular attention. A student nurse gradually builds a professional identity through university, placement, friendships, difficult shifts and the first moments of feeling useful at the bedside. Cancer can interrupt that process without warning.
Maya may watch classmates complete placements she was meant to attend. She may worry about practice hours, assessments, progression and whether treatment will delay her qualification. Returning later may also feel different: a hospital that once represented learning may now be associated with scans, treatment and frightening news.
The nursing response is not to promise that she will definitely return to the course. It is to recognise that education is part of her life and help her reach the people who can explore realistic options with her.
There is another shift too. Maya knows how healthcare works, but she is no longer standing beside the bed. She is in it. Staff should avoid both extremes: treating her as though she knows nothing because she is a patient, or treating her as though she needs less care because she is a student nurse. Ask what level of explanation she wants and give her permission to be a patient.
What can the student nurse contribute?
Under appropriate supervision and within competence, a student nurse can perform and report physiological and neurological observations, recognise and escalate deterioration, assess and document symptoms, support prescribed care, listen to Maya’s priorities, help her reach the registered nurse or specialist team when questions arise and include her own concerns in handover.
The student is not responsible for staging Maya’s cancer, interpreting molecular testing, giving a prognosis, selecting cancer treatment or advising her whether she can continue her nursing degree.
Evaluation: two weeks later
Maya has now had further specialist review. Her pathology, molecular and imaging information has been considered by the multidisciplinary team and treatment planning is progressing. Her respiratory symptoms remain stable and she has had no new focal neurological deficit or seizure. Symptom-control treatment has reduced her headaches.
She is still frightened and fatigued. She has spoken with her university and has begun discussing an interruption or adjustment to study rather than feeling she must make an immediate irreversible decision about leaving the course. She has met her clinical nurse specialist and knows how to access support between appointments.
When asked what is most difficult, Maya says, “I know I’m still me. I just don’t know what my life looks like now.”
That is not a failed care-plan outcome. It is an honest point in adaptation to life-changing illness. Her care plan should continue to address safety and symptoms while leaving space for uncertainty, identity and the future she wants to discuss.
Documentation example
“11:20. Ongoing care needs reviewed with Maya following diagnosis of lung adenocarcinoma with regional nodal disease and solitary brain metastasis. Alert and orientated; observations stable. Reports persistent exertional breathlessness, cough, fatigue and intermittent headache. No new focal weakness, speech or visual disturbance reported. Neurological red flags and urgent contact route reinforced. Maya identifies disruption to second-year nursing studies and uncertainty about future qualification as significant current concerns. Would like support to understand university options but does not want decisions made on her behalf. Agrees to relevant support discussion/referral. Information needs reviewed; Maya requests clear explanations despite healthcare background. Continue symptom and neurological assessment, treatment-planning support and person-centred review.”
Reflection
Before leaving Maya’s story, consider why you should not assign a complete TNM category from partial information; which neurological changes need immediate escalation; why new breathlessness should not automatically be attributed to cancer; how being a student nurse might alter the experience of receiving cancer information; and how you would evaluate an identity-related care-plan goal without expecting Maya to “accept” her diagnosis.
References and further reading
Nursing and Midwifery Council (NMC). Standards of proficiency for registered nurses.
This worked care plan is for student learning and does not replace individual clinical assessment, specialist oncology advice, local policy or supervised practice.