Lung Cancer

By Holly Winn and Cathy Mac Donald

Objectives
To To To To provide a general overview of lung physiology explore the types and classifications of lung cancer provide causes and risk factors of lung cancer present the signs and symptoms of lung cancer in throughout its progression To explore assessment and diagnostic information of lung cancer To introduce diagnostic staging specific to lung cancer To discuss treatments and side effects of lung cancer To present post-op complications for clients with lung cancer To explore the nurses role and nursing interventions for a client with lung cancer To explain preventive health strategies regarding lung cancer To present appropriate nursing diagnoses for clients living with lung cancer To provide and critically discuss a case study

General Overview of Lung Physiology: Breathing

Healthy lung tissue

Diseased Lung Tissue

Types of Lung Cancer

Two main Types of Lung Cancer:
Small Cell Lung Cancer
(20-25% of all lung cancers)

Non Small Cell Lung Cancer (most common ~80%)

Small Cell Lung Cancer

Non-small cell lung cancer

1. Squamous cell carcinoma 2. Adenocarcinoma 3. Large cell carcinomas

Squamous cell carcinoma

Moderate to poor differentiation makes up 30-40% of all lung cancers more common in males most occur centrally in the large bronchi Uncommon metastasis that is slow effects the liver, adrenal glands and lymph nodes. Associated with smoking Not easily visualized on xray (may delay dx) Most likely presents as a Pancoasts tumor

Adenocacinoma
Increasing in frequency. Most common type of Lung

cancer (40-50% of all lung cancers). Clearly defined peripheral lesions (RLL lesion) Glandular appearance under a microscope Easily seen on a CXR Can occur in non-smokers Highly metastatic in nature
Pts present with or develop brain, liver, adrenal or bone metastasis

Large cell carcinomas

makes up 15-20% of all lung cancers Poorly differentiated cells Tends to occur in the outer part (periphery) of lung,

invading sub-segmental bronchi or larger airways Metastasis is slow BUT Early metastasis occurs to the kidney, liver organs as well as the adrenal glands

http://www.youtube.com/watch?v=3wzjqbh besI.

Lung Cancer Re-cap

Small Cell Lung Cancer Non-Small-Cell Lung Cancer
Squamous cell Adenocarinoma

Causes and Risk factors of Lung Cancer

Signs and Symptoms of Lung Cancer

Sometimes lung cancer does not cause any symptoms and is only

found in a routine x-ray. If a person with lung cancer does have symptoms, they will depend on the location of the tumour in their lung. It is also imperative to note that the same symptoms can be caused by other conditions, so may not necessarily mean cancer. Therefore it is important to consult a doctor when symptoms are present. Signs and symptoms also depend upon the location, size of the tumor, degree of obstruction and existence of metastases

Signs and Symptoms of Lung Cancer

There are two types of signs and symptoms of lung cancer: 1) Localized involving the lung. 2) Generalized involves other areas throughout the body if the cancer has spread.

Localized Signs and Symptoms

Cough Breathing Problems, SOB, stridor Change in phlegm Lung infection, hemoptysis Hoarseness, Hiccups Wt loss Chest Pain and tightness Pancoats Syndrome Horners Syndrome Pleural Effusion Superior Vena Cava Syndrome Fatigue

Generalized Signs and Symptoms

Bone pain Headaches, mental status changes or neurologic
findings Abdominal pain, elevated liver function tests, enlarged liver, gastrointestinal disturbances (anorexia, cachexia), jaundice, hepatomegaly r/t liver involvement Weight loss

Early/late Signs and Symptoms Of Lung Cancer

Early Signs
Cough/chronic cough Dyspnea Hemoptysis Chest/shoulder pain

Late signs
Bone pain, spinal cord compression Chest pain/tightness Dysphagia Head and neck edema

Recurring temperature
Recurring respiratory infections

Blurred vision, headaches

Weakness, anorexia, weight-loss, cachexia Pleural effusion Liver metastasis/regional spread

Diagnostic Tests

CXR CT Scans MRI Sputum cytology Fibreoptic bronchoscopy Transthoracic fine needle aspiration

Laboratory Tests
Blood Tests
*CBC-to check red/white blood cell & platelets -to check bone marrow and organ function *Blood Chemistry Test-to assess how organs are functioning such as liver and kidney Biopsy-to determine if the tumor is cancer or not -to determine the type of cancer -to determine the grade of cancer (slow or fast)

Biopsy

Endoscopy
Bronchoscopy Mediastinoscopy VATS (video assisted thoracoscopic surgery)

Bronchoscopy

Mediastinoscopy

VATS (video assisted thoracoscopic surgery)

Nursing Management for post endoscopic procedures

Bronchoscopy Monitor V/S; NPO status maintained until return of gag reflex. Fever up to 101F can be expected afterwards Mediastinoscopy Monitor VS; potential for bleeding, infection and dyspnea; NPO status until return of gag reflex VATS Monitor V/S; potential for bleeding, infection and dyspnea; NPO status until return of gag reflex

Post-op complications for those with lung cancer

Airway obstruction, dyspnea, hypoxemia, respiratory failure Anesthesia side effects (N/V) Bleeding (hypotension, cardiogenic shock) Cardiac dysthymias, CHF, fluid overload Fever, sepsis Pneumonia Pneumothorax Pulmonary embolus Wound dehiscence Prolonged hospitalization Death

Nursing pulmonary post-op considerations/interventions

Positioning in bed, Monitor V/S Prevention of respiratory complications
Early ambulation, DB&C, incentive spirometer, managing dyspnea

Prevention of deep vein thrombosis Early ambulation Pain management Infection control

Educating the patient

Inform the patient what to expect, from administration of

anesthesia to thoracotomy and the likely use of chest tubes and a drainage system postoperatively. Tell the patient about the administration of oxygen postoperatively and the possible use of a ventilator. Explain the importance of frequent turning to promote drainage of lung secretions. Instruct the proper use of an incentive spirometry and how to perform diaphragmatic and pursed-lip breathing techniques. Teach the patient to splint the incision site with hands, a pillow or a folded towel to avoid discomfort

Cancer Staging
Clinical Staging Pathological Based on the examination of the tissue samples obtained from the primary tumor, nodes or metastasis Helpful in planning additional treatment and follow-up

based on findings gathered by the doctor used to plan the initial therapy may be modified by additional information found during pathological examination

Cancer Staging Systems

The most common staging system for lung
cancer is the TNM System developed by the International Union Against Cancer (UICC). Guides best course of treatment Estimates prognosis It is only useful in staging NSCLC, when surgery is considered.

TMN Staging system for Lung Cancer

T= Tumors : tumor size, (local invasion)
N= Node : node involvement (size and type) M= Metastasis : general involvement in organs and tissues

Lung Cancer Staging Continued

T: Tx, T0, Tis, T1-T4 (T3
tumors greater than 7cm, T4 is a tumor of any size) N: N0, N1, N2, N3 M: M0, M1a, M1b

Medical Management
The three main cancer treatments
are: *surgery (lung resections) *radiation therapy *chemotherapy Other types of treatment that are used to treat certain cancers are hormonal therapy, biological therapy or stem cell transplant.

Side effects of treatments

Surgery Pain Radiation fatigue Chemotherapy Anemia, thrombocytopenia

Hemotomas
Hemmorhage Altered respiratory function Risk for atelectasis, pneumonia, hypoxia Risk for DVT

Decreased nutritional intake

Radiodermatitis

Fatigue
Alopecia, SOB

Decreased hematopoietic Cold, pale function Risk for Pneumonitis, esophagitis, cough N/V Grief Tingling Irritable Dizzy, weak

Lung resections
Lobectomy: a single lobe of lung is removed Bilobectomy: 2 lobes of the lung are removed (only on R

side) Sleeve resection: cancerous lobe is removed and segment of the main bronchus is resected Pneumonectomy: removal of entire lung Segmentectomy: a segment of the lung is removed Wedge resection: removal of a small, pie-shaped area of the segment Chest wall resection with removal of cancerous lung tissue: for cancers that have invaded the chest wall

Complimentary Therapies
Includes acupuncture and massage and pharmacological approaches
such as vitamins and herbal medicine.

One study showed that herbal medicine is used by approximately

48% of lung cancer patients in China.

These herbal therapies combined with chemotherapy increases

survival in non-small-cell lung cancer by up to 42%, compared with chemotherapy alone.

Complimentary Therapies contd

Foods: Green tea, N-acetyl cysteine,
Curcumin, Garlic, Fish Oil, Lactobacillus, ginseng root

Complimentary Therapies contd

Mind-body: help to reduce anxiety, mood

disturbance, or chronic pain in cancer patients (audiotapes, videotapes, books, music, relaxation, yoga, meditation). Acupuncture Hypnosis Massage therapy

Prognostic Factors
The best estimate on how a patient will do based on:
*type of cancer cells *grade of the cancer *size or location of the tumor *stage of the cancer at the time of diagnosis *age of the person *gender *results of blood or other tests *a persons specific response to treatment *overall health and physical condition

Prevention: Primary

Avoid the use of tobacco smoke Personal and family hx are important risk factors Know environmental carcinogens that increase risk Chemoprevention:

Consuming carotenoids, Vit A, retinoids Vit E, selenium, Vit C, fat

Prevention: Secondary
Aim is to early diagnose high risk
populations via screening CXR, MRI, CT scans, sputum cytology

Prevention: Tertiary
Targeted at people who survived a cancer
disease Assists them to retain an optimal level of functioning regardless of their potential debilitating disease

Nurses Role with clients with lung cancer

Coping with diagnosis Pre/post treatment education Education on managing breathlessness Referrals for stop smoking advisor Referring to services such as hospice care, dietitian, massage therapy, counselors Advocate for appointments, scans etc. Educate client and family about disease process, treatment options and S/E Provide resources for support groups and where information and be sought

Nursing Interventions
Management of N/V, weakness, fatigue, wt loss, appetite loss,

altered taste Pain management, education to avoid concern about addiction, pharmacological and non-pharmacological Elevate HOB Splinting to aid in coughing Teach breathing exercises to diaphragmatic excursion and WOB DB&C Provide a vaporizer Relaxation techniques to anxiety r/t SOB Encourage energy conservation Encourage small amts of high-calorie and Pn foods freq.

Nursing Diagnoses
Ineffective breathing pattern r/t loss of adequate ventilation Impaired gas exchange r/t excessive or thick secretions 2 to
smoking; r/t decreased passage of gases between alveoli of lungs and vascular system Chronic pain related to Stage IV NSCLC diagnosis as evidenced by client reporting pain in right chest and lower ribs. Risk of infection related to altered immune system secondary to effects of cytotoxic drugs. Risk for disturbed self concept related to changes in lifestyle. Nausea related to effects of chemotherapy as evidenced by client reporting feeling nauseated. Risk for deficient fluid volume related to gastrointestinal fluid loss secondary to vomiting. Fatigue related to chemotherapy secondary to stage IV NSCLC as evidenced by client reporting he no longer has the energy to play with his grandchildren or visit his friends.

Case Study & QUESTIONS

John is a 44 year old man from NFLD. He worked in a machine shop
since he was 18. He was laid off for 6 months, has a new girlfriend and custody of 3 kids from a previous marriage. They live in a low SES neighborhood and is stressed about not having work to support his family. He cant afford to move out west and doesnt want to leave his children. Both of his parents have passed away. (Mum from lung cancer and father from prostate cancer). Smoking helps to manage his stress. He has smoked about a pack a day since he was 16. Growing up, both of Johnathans parents smoked as well as most of his aunts and uncles. His girlfriend is always complaining at him because he is coughing and is sick all of the time. He says its just from the smokes. Johnathan also noticed that he is becoming short of breath and cant play with his kids like he used too. The past 4 months he has coughed up blood in the sink but attributes that to getting older and coughing too hard.

References
Carpenito-Moyet, L.J. (2009). Nursing Diagnosis; Application to clinical
practice (13th ed.). Philadelphia, P.A.: Lippincott Williams & Wilkins

Cassileth, B., Deng, G., Gomez, J., Johnstone, P., Kumar, N., Vickers, A. Day, R.A., Paul, P., Williams, B. Smeltzer, S.C., Bare, B. (2010). Brunner &
Philadelphia, P.A.: Lippincott Williams & Wilkins. Otto, S. (2001). Oncology Nursing (4th ed.). St. Louis, Missouri: Mosby Inc.

Suddarths Textbook of Canadian Medical-Surgical Nursing (2nd ed.).

http://nursingcrib.com/nursing-notes-reviewer/lung-cancer/ http://news.bbc.co.uk/2/hi/health/7130216.stm http://news.bbc.co.uk/2/hi/health/7130216.stm www.cancer.ca