ihi lung cancer

7/27/2019 IHI Lung Cancer

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By Marian Jeffries, APRN,BC, FNP,C, MSN;

Rachel Townsend, RN, AND;

and Emily Horrigan, RN,C, BSN

Nursing2007, DecemberEarn 2.0 ANCC/AACN contact hoursOnline: http://www.nursing2007.com

2007 Lippincott Williams & Wilkins
http://www.nursing2007.com/http://www.nursing2007.com/http://www.nursing2007.com/


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1. Identify the two major types of lung cancer.

2. Identify the presenting signs and symptomsof lung cancer.

3.

Indicate postoperative nursing measures fora person with lung cancer.


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Most common malignancy in the world Affects over 3 million people

Causes more deaths in the United States than

breast, prostate, and colon cancers combined Only about 16% are found in early stages

49% survival when detected at localized stage

The American Cancer Society estimates that213,380 new cases of cancer of the lung and

bronchus will be diagnosed in the United States andthat 160,390 people will die of the disease in 2007.


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Current or previous tobacco smoking Preexisting lung disease Genetic predisposition Environmental exposure

Air pollution Secondhand smoke Toxic chemicals or fumes Radon gas

Asbestos fibers Talc dust Radiation

The combination of smoking andasbestos exposure greatly

increases the risk of lung cancer.


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Chest x-ray can detect lesions 1 cm Sputum cytology can detect malignant cells

Spiral low-dose computed tomography

(LDCT) has successfully detected early lungcancers in smokers and former smokers, butalso detects other lesions that are laterdetermined nonmalignant

The American College of Chest Physicians recommendsagainst screening for lung cancer with LDCT, chest

X-ray, or sputum cytology, except in the context of awell-designed clinical trial.


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Small cell lung cancer (SCLC) Small cell carcinoma (oat cell carcinoma)

Mixed small cell/large cell carcinoma

Combined small cell carcinoma

Non-small cell lung cancer (NSCLC) Squamous cell carcinoma

Adenocarcinoma

Large cell carcinoma


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Accounts for 15% of all lung cancers Strongly linked to cigarette smoking

Spreads quickly

Patients commonly have signs and symptomsof metastasis before cancer is detected

Poor prognosis

Treated with chemotherapy and radiation

Surgery not an option


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Accounts for 25% to 30% of all lung cancers inthe United States.

Linked to smoking history Arises from the epithelium covering and

lining organ surfaces

Commonly found centrally, near a bronchus

Tends to grow and metastasize slowly


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Responsible for about 40% of lung cancers inthe United States

Commonly affects nonsmokers and women

Bronchioloalveolar carcinoma, a subtype,forms deep in the lungs air sacs


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Accounts for 10% to 15% of all lung cancers inthe United States.

Most often affects smaller bronchioles near

the surface of outer edges of the lungs Grows and metastasizes quickly


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Difficult or laboredbreathing

Shortness of breath

Hoarseness

Stridor Chronic fatigue

Loss of appetite

Bone pain, aching

joints Unexplained weight

loss

Cough > 2 weeks Persistent chest,

shoulder, or back painaggravated by deep

breathing or coughing Change in sputum

color or volume

Blood in sputum

Wheezing

Recurrent pneumoniaor bronchitis


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Chest X-ray Pinpoints consolidation, obstructive pneumonitis, or

pneumothorax

Spiral computed tomography (CT) Shows tumor mass and enlarged lymph nodes Lymph nodes >1 cm are suspicious; nodes


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Integrated PET/CT Potentially a more sensitive and accurate test for

early stage

Endobronchial ultrasound Assesses the depth of tumor invasion, especially

with tumors close to the trachea, carina, and mainbronchus

Magnetic resonance imaging (MRI) Rarely used for diagnosis Helps detect vascular and chest wall invasion

Helps detect metastases to the brain or spinal cord


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Sputum cytology To identify cancer cells in mucous coughed up from

the lungs

Bronchoscopy

To visualize a tumor or obstruction Can biopsy specimen or tissue washings for

pathology

Mediastinoscopy To visualize areas between the lungs, examine the

lymph nodes, and get biopsy specimens Needle biopsy

To collect fluid or tissue


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Positive tissue biopsy from primary tumorconfirms diagnosis

Microscopic examination differentiates thecell type

Staging is based on Cell type

Primary tumor size and location

Lymph node involvement

Presence of distant metastases


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SCLC Staged as limitedor extensive

Limited stage typically means that cancer is presentin one lung and possibly the lymph nodes on the

same side NSCLC

Staged using the TNM system: Extent of the primary Tumor Involvement of regional lymph Nodes Presence ofMetastases


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Surgery Radiation therapy

Chemotherapy

Adjuvant therapy Palliative care

The patient may undergo more than one type

of therapy at the same time or consecutively.


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Complete removal of tumors offers the bestchance of survival for patients with NSCLC.

Approach depends on Type of lesion

Location

Patients age and overall health

Surgeons preference


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Video-assisted thorascopic surgery Two to five small incisions Can be used to remove smaller lesions or one or more lung

lobes

Thoracotomy Incision through the chest wall Posterior approach for pneumonectomy Anterior or unilateral approach for any procedure requiring

increased visualization clamshell incision a bilateral anterior approach for

bilateral excisions of multiple nodules or segments

Sternotomy Incision through the sternum Access to bilateral pulmonary lesions, the heart, major

blood vessels, and lymph nodes


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Mediastinoscopy Collar incision To visually assess the mediastinum and the anterior

surface of the lungs To biopsy the paratracheal lymph nodes

Bronchoscopic coring or debulking Improves ventilation when tumor is blocking the

airway

Bronchial stent placement Palliative technique Bolsters the tracheal or bronchial airway with a

silicone stent to improve ventilation


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Shrinks tumors by damaging DNA in thecancer cells to kill them

Can be administered before or after surgery,

as a single modality, or with chemotherapy Shrinking a tumor before surgery can improve

resectability, but changes in local tissue cancomplicate postoperative healing


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External beam radiation Divided doses given once or twice a day over a period of weeks

Intensity modulated radiation therapy Computer-programmed dosing delivered in three dimensions Causes less damage to surrounding tissues

Proton beam therapy Targets very small tumors with very high radiation doses to minimize

damage to healthy tissue Commonly used to destroy metastatic lesions in the brain, head, and neck

and to treat children

Brachytherapy Delivers radiation internally via an implant Spares noncancerous tissues Occasionally reduces the need for surgery Can help relieve symptoms but isnt a cure


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Can help slow tumor growth Most common treatment for SCLC Also used to manage advanced stages of

NSCLC Can be used in conjunction with radiation for

a greater effect Work by overwhelming the cancer cells capacity to

repair DNA damage, resulting in cell death

Attempt to localize damage to cells and tissuesassociated with the cancer, but noncancerous stemcells in the bone marrow are generally affected also


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Drug selection varies with tumor type andstage

Randomized trials show better survival ratesfor patients who receive combined regimensgiven simultaneously or sequentially

Platinum-based combination preferredbecause of efficacy and toxicity profiles


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Drugs to treat SCLC cisplatin

etoposide

topotecan Drugs to treat NSCLC

cisplatin or carboplatin combined with paclitaxel,docetaxel, gemcitabine, vinorelbine, irinotecan,etoposide, vinblastine, or bevacizumab


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Interfere with specific molecules needed forcarcinogenesis and tumor growth

Target the epidermal growth factor receptor

(EGFR) thats evident in many cases of NSCLC Examples:

gefitinib (Iressa)

erlotinib (Tarceva) 2nd-line agent for advanced

cases


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Monitor level of consciousness and vital signs every2-4 hours or more often Evaluate pulmonary status

Color Breath sounds Respiratory rate, depth, and pattern Arterial blood gases

Perform continuous cardiac monitoring (at risk fordysrhythmias, especially atrial fibrillation) Reposition the patient to optimize gas exchange

Elevate head of bed 30 to 45 Get patient out of bed Ambulate patient Turn patient from side to side while in bed if he had pneumonectomy,

keep his operative side down


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Administer supplemental oxygenvia a face maskwith humidification Help patient mobilize secretions

Provide pain management

Coughing and deep breathing (every 1-2 hours for first

24 hours) Incentive spirometry

Care for chest tubes Examine system

Assess amount and characteristics of drainage Notify the surgeon if >150 mL/hr of drainage Reinforce dressing as needed


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Assess pain every 2 hours and administer analgesicsas ordered Continuous epidural infusion of an opioid is preferred PCA is also an option Most switch to nonopioid 48-72 hours postop

Help prevent venous thromboembolism Graduated compression stockings or intermittent

pneumatic compression Anticoagulants

Clean and protect incision site and monitor drainage Observe for signs of nonhealing, dehiscence, or infections If no drainage after 24 hours, surgeon may remove the

dressing and leave the wound open to air


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Help patient sit, stand, and ambulate within first24 hours Monitor intake and output

Urine output should be at least 0.5 mL/kg/hour

Administer fluids and diuretics as ordered

Obtain and monitor daily serum electrolytes Advance diet based on tolerance, aspiration risk,bowel sounds, and special requirements Follow prescribed bowel regimen Remove indwelling catheter as soon as possible


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Activity, pain management, and incision care Call surgeon if redness, swelling, or drainage of

incision increases or if he develops fever, increasedpain, or shortness of breath

No lifting anything heavier than a half gallon of milkfor 6 weeks

If he smokes, urge him to quit and tell him tolimit exposure to secondhand smoke

Pain should gradually diminish over 3 to 6

weeks Follow-up with surgeon, typically in 3 weeks


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Chemotherapy, radiation, and surgery can be used torelieve signs and symptoms Radiofrequency ablation

Delivers current that heats and destroys tumor cells Minimally invasive Commonly done as an outpatient

Photodynamic therapy For an obstructing endobronchial tumor thats untreatable by

surgery or radiation Photosensitizing drug injected which binds to lipoproteins in his

blood for transport to lipoprotein-hungry cancer cells 40-50 hours after injection, laser light is applied via

bronchoscopy which activates the drug and disrupts cancer cells Can be performed as an outpatient and may be repeated Patient must avoid sunlight and bright indoor light for 6 weeks

because of extreme photosensitivity


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Dyspnea Differentiate from anxiety

Treatment measures

Nebulizer treatments

Secretion-clearance techniques Positioning

Decreasing oxygen requirements by limiting physicalactivity

Morphine via nebulization

Low-dose opioids with positioning and musclerelaxation techniques

Noninvasive positive-pressure ventilation


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Pain Analgesics

Address needs as his comfort level changes

Usual plan is to gradually reduce opioids over 3 weeksand supplement them with NSAIDs or acetaminophen

Complementary and alternative therapies Acupuncture

Massage therapy

Relaxation techniques

Support groups

Reiki therapy Vitamin and dietary supplements

Herbal products

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