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