# Situation: A 64-year-old man who has smoked 1 pack of cigarettes a day for 40 years is admitted with newly diagnosed small cell lung cancer. Chemotherapy with cisplatin and etoposide is planned. Two weeks later, the nurse notes these findings: Face, neck, and both arms: swollen; neck and upper chest veins distended Breathing: short of breath, worse when lying flat Back and legs: no back pain; leg strength and sensation normal Serum potassium: 4.2 mEq/L (3.5–5.0); serum calcium: 9.4 mg/dL (8.6–10.2) Which action should the nurse take?

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> subject: Nursing Practice III — Care of Clients with Problems in Surgery, Oxygenation, Fluid and Electrolytes, Infectious, Inflammatory and Immunologic Response, Cellular Aberrations

## 문제

Situation: A 64-year-old man who has smoked 1 pack of cigarettes a day for 40 years is admitted with newly diagnosed small cell lung cancer. Chemotherapy with cisplatin and etoposide is planned.

Two weeks later, the nurse notes these findings:
Face, neck, and both arms: swollen; neck and upper chest veins distended
Breathing: short of breath, worse when lying flat
Back and legs: no back pain; leg strength and sensation normal
Serum potassium: 4.2 mEq/L (3.5–5.0); serum calcium: 9.4 mg/dL (8.6–10.2)
Which action should the nurse take?

## 보기

1. Start cardiac monitoring and withhold all potassium sources
2. Keep him flat and log-roll him until an urgent spine scan
3. Start intravenous saline and prepare the ordered bisphosphonate
4. Raise the head of the bed and give oxygen as ordered **✔ 정답**

**정답: 4**

## 해설

Each option is the first action for a different oncologic emergency, so the findings must be matched first. Swelling of the face, neck, and arms with distended upper chest veins and orthopnea indicates superior vena cava syndrome; the normal back and leg examination, calcium, and potassium rule out the other emergencies. The nurse raises the head of the bed, gives oxygen, avoids arm lines where possible, and notifies the provider.

## 심화 해설

Clinical picture and first priority
This patient’s findings point to superior vena cava syndrome (SVCS). The swollen face, neck, and both arms, distended neck and upper chest veins, and shortness of breath that worsens when lying flat are classic signs of impaired venous return through the superior vena cava. In a man with newly diagnosed small cell lung cancer, the most likely cause is tumor compression or occlusion of the SVC [1][2]. The normal back and leg examination makes spinal cord compression unlikely, and the normal potassium and calcium levels rule out tumor lysis syndrome and hypercalcemia as the immediate problem. The first nursing action is to reduce venous congestion and support oxygenation: raise the head of the bed and give oxygen as ordered.

Why the other options do not fit
Each option is the first action for a different oncologic emergency. Watch out! Matching the findings to the correct emergency is the key to choosing the right first action.

| Finding in this patient | Oncologic emergency it suggests | Correct first action |
| --- | --- | --- |
| Face, neck, arm swelling; distended upper chest veins; orthopnea | Superior vena cava syndrome | Elevate head of bed, give oxygen, notify provider |
| Back pain, leg weakness, sensory loss | Spinal cord compression | Keep flat, log-roll, urgent spine imaging |
| Hyperkalemia, hyperphosphatemia, hypocalcemia, rising creatinine | Tumor lysis syndrome | Cardiac monitoring, IV fluids, hold potassium |
| Hypercalcemia with confusion, constipation, polyuria | Hypercalcemia of malignancy | IV saline, bisphosphonate |

This patient has no back pain and normal leg strength and sensation, so spinal cord compression is not supported. The potassium is 4.2 mEq/L and calcium is 9.4 mg/dL, both within normal limits, so tumor lysis syndrome and hypercalcemia are not the current problem. Therefore, cardiac monitoring with potassium restriction, flat positioning with log-rolling, and IV saline with bisphosphonate are not the priority actions here.

Pathophysiology of SVCS
The superior vena cava is a thin-walled, low-pressure vessel that returns blood from the head, neck, upper extremities, and upper thorax to the right atrium. When a tumor compresses or invades the SVC, venous return is obstructed. This raises venous pressure upstream, producing edema of the face, neck, and arms, distended veins in the upper chest and neck, and respiratory symptoms. Lying flat worsens the obstruction because gravity no longer assists venous drainage, which explains the orthopnea [1]. Elevating the head of the bed uses gravity to reduce venous congestion and ease breathing. Oxygen helps correct any hypoxemia from impaired gas exchange or airway edema.

Nursing management priorities
SVCS is considered a relative medical emergency because severe obstruction can progress to laryngeal or cerebral edema [1][2]. Nursing care focuses on supporting breathing and reducing pressure in the upper body. Key point! Elevate the head of the bed, administer oxygen as ordered, and notify the provider promptly. Additional measures include avoiding venipuncture or IV lines in the arms when possible, because impaired venous return makes arm veins poor access sites and increases the risk of complications [1]. Fluid management may include diuretics or corticosteroids as part of the medical plan, but the nurse’s immediate independent and ordered actions center on positioning and oxygenation [2].

Why small cell lung cancer matters
SVCS is primarily associated with small cell lung cancer [1]. Small cell carcinoma often arises centrally in the chest, near the SVC, and grows rapidly. This anatomic location explains why SVCS can appear early in the disease course, sometimes even before the cancer diagnosis is confirmed. Because small cell lung cancer is generally chemosensitive, chemotherapy with cisplatin and etoposide may help shrink the tumor and relieve the obstruction over time, but the immediate nursing priority remains supportive care for respiratory and venous congestion [1][2].References (research sources)

- [1]Superior vena cava syndrome.Research articleHaapoja IS, Blendowski C (1999) · DOI: 10.1016/s0749-2081(99)80006-0

- [2]Clinical management of superior vena cava syndrome.Research articleVarricchio C (1985)

## 임상 시나리오

Superior Vena Cava Syndrome: First Nursing ActionsRecognize venous obstruction in lung cancer and act fast
In a patient with small cell lung cancer, facial, neck, and arm swelling with distended upper chest veins and orthopnea indicates superior vena cava syndrome. The first priority is to raise the head of the bed and give oxygen as ordered to reduce venous congestion and support breathing.

Normal back and leg examination rules out spinal cord compression, while normal potassium 4.2 mEq/L and calcium 9.4 mg/dL rule out tumor lysis syndrome and hypercalcemia. Match findings to the correct oncologic emergency before acting.

CautionAvoid arm IV lines and blood pressure cuffs when possible in SVC syndrome because impaired venous return increases complications. Notify the provider promptly after initial positioning and oxygen.

## 핵심 개념

- **Superior vena cava syndrome** — Obstruction of the SVC causing facial, neck, and arm swelling, distended upper chest veins, and dyspnea, often from lung cancer
- **Orthopnea** — Shortness of breath that worsens when lying flat, seen in SVC syndrome and heart failure
- **Tumor lysis syndrome** — Oncologic emergency with hyperkalemia, hyperphosphatemia, hypocalcemia, and rising creatinine after chemotherapy
- **Spinal cord compression** — Oncologic emergency presenting with back pain, leg weakness, and sensory loss requiring flat positioning and urgent imaging

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