Nursing Management of the Patient with Lung Cancer

A 68-year-old male patient who has smoked three packs of cigarettes a day since his teen years is seeing his primary care provider for pulmonary symptoms including dyspnea and a chronic productive cough. The patient also states he has pain in his chest, shoulder, and back. The primary care provider suspects the patient has lung cancer and is ordering diagnostic tests. 1. What diagnostic tests would the nurse anticipate the physician ordering? What nursing implications are involved with the tests? -cytologic exam of sputum -when pleural effusion is present fluid can be obtained by thoracentesis for cytology -chest x ray -fiber optic bronch -throrascopy -needle bx of lymph nodes -MRI -ABG  Dx by CXR,CT, PET, Sputum Cytology, Bronchoscopy, Mediastinoscopy 2. What are the warning signals of lung cancer that the nurse may teach the client and family? -change in resp pattern -persistent cough or change in cough -blood streaked sputum -rust colored sputum -frank hemoptyis -chest pain or tightness -shoulder arm or chest wall pain -recurring episodes of pleural effusion -dyspnea -wheezing -weight loss -clubbing of fingers 3. What can the nurse do to help chronic smokers overcome their smoking habit and thus help prevent lung cancer? -education -offer smoking sensation -get them in contact with support groups -

Diagnostic testing confirms the patient has small cell carcinoma of the lung. 4. What surgical procedure would most likely be planned for this patient? What would the nurse teach the patient about the procedure? Lung cancer surgery can involve removal of the tumor only, removal of the entire lung (pneumonectomy), removal of the lung segment lobectomy. Relieve anxiety, teach about location of surgery, that there will be incisions, sgiykder exercises and the chest tube and drainage system. Surgery Wedge Resection Small area of lung Segmental Resection Partial lobe Lobectomy Most common One lobe of lung Pneumonectomy Entire lung The space fills with fluid which later semisolidifies The patient is admitted to the hospital for surgery. After recovering in the post-anesthesia care unit, he is admitted to the pulmonary nursing floor. He is stabilized and currently resting comfortably. 5. Develop three nursing diagnoses with expected outcomes and nursing interventions for the patient undergoing surgery for lung cancer. Ineffective Breathing Pattern pts breathing pattern is maintained as evidence by normal skin color and regular resp rate and pattern. Intervention: Asses lung sounds, assess skin color, monitor chest x ray reports Ineffective airway clearance pts airway is mobilized and airway is maintained free of secretions as evidence by clear lung sounds and ability to cough up secreations effectively after deep breaths. Interventions: Administer humidified O2, Assist pt in cough and deep breathing exercises, early ambulation Acute Pain pts pain is relieved as evidence by verbalization of pain relief and relaxed facial expressions. Interventions: Anticipate need for medication, respond immediately to complaints of pain, schedual rest periods. Risk for impaired gas exchange

6. Describe the nursing management of the patient s chest tube. Assess the patient The system must remain intact and below the level of the chest Position and reposition patient to promote lung expansion and comfort Address pain Maintain sterility Upon assessing the patient later in the shift, the nurse notes that he is unusually lethargic, diaphoretic, and difficult to arouse. The nurse obtains ABGs which reveal a pH of 7.30, PaCO2 of 55, PaO2 of 60, HCO3 of 24, Oxygen saturation of 88%. 7. Interpret the ABGS: Respritatory Acidosis 8. List in priority order three nursing actions that should be immediately implemented by the nurse. Correct the underlying problems and monitor for changes. O2 therapy Pulmonary hygiene Drug therapy Vent support 9. What are the priority goals in managing this client? Correct the underlying problem and monitor for changes

The patient is admitted to the ICU. He is intubated and on a ventilator at the following settings: SIMV mode, rate 12, TV 700, Pressure support 10. 10. What is the difference between SIMV mode and assist control? Assist-Control Mode The patient can initiate breaths with this mode A preset Tidal Volume is delivered as in Assist mode If the patient does not initiate a breath or does not initiate frequent enough breathes the machine will initiate respirations at a set rate Most commonly used mode May cause hyperventilation or acid base imbalance if respiratory rate is high Synchronization of Ventilation SIMV- (Synchronized) Intermittent Mandatory Ventilation Commonly used with weaning- Helps condition respiratory muscles and is also used for ventilation The ventilator will deliver a set number of respirations with a set TV however the patient may breathe on his/her own between these set breathes 11. Describe the process of weaning the patient from the ventilator. What assessment criteria indicate if the patient can be extubated? Preweaning- Assessment Spontaneous Respiratory Rate Muscular Strength and Endurance NIP(negative inspiratory pressure) PEP (positive expiratory pressure) Vt and VC Other Factors Hemodynamic status Nutrition Pain Etc. Patient Should Be Well Rested and Fairly Comfortable

Process of Weaning Individual Plan Psychological Support Involve and Include Family in Teaching and Support Do During the Day Trials to Permit Assessment and Determine if Extubation will be Tolerated Methods of Weaning SIMV with SIMV breaths gradually reduced CPAP and or PSV added to SIMV PSV (Pressure Support Ventilation) augments inspiration with spontaneous respirations and may help recondition respiratory muscles. Pressure is gradually decreased or the rate is gradually decreased as the patient takes over the work of breathing T-Piece technique- ventilator is replaced with T-piece or CPAP supplying humidified O2- FIO2 may be higher than ventilator FIO2 Monitor During Weaning VS Respiratory Assessment Vt, NIP, NEP,VC Pulse Ox Signs of Respiratory Distress, Hypoxia

The patient stabilizes and returns to the regular nursing unit after a 3-day stay in the ICU. 12. What nursing interventions will help prevent the development of atelectasis and pneumonia in his remaining lung? Deep Breathing Coughing Ambulation 13. What discharge instructions should the nurse include in the teaching plan? Medications When to call the Dr. Ambulation Coughing/Deep breathing Sit when short of breath

Drug Classification of the week: ACE Inhibitors

1. Is there a common suffix for this drug class? PRIL 2. List several drugs that fall under this classification. Give the generic and trade name for each. y Captopril y Lisinopril y Enalapril 3. What are the actions of these medications? ACE Inhibitors work in the lungs by blocking the conversion of a specific protein from its inactive to its active form. This protein, in its active form, can cause constriction of small blood vessels, called arterioles, and exhert various other effects which can raise blood pressure. By blocking the formation of this active protein, blood pressure is lowered over time. 4. What are the common uses? Are there any off-label uses?

ACE Inhibitors are a commonly available and widely prescribed class of anti-high blood pressure medicine. Some ACE Inhibitors are also prescribed to patients
y y y

After a heart attack (lisinopril, captopril, ramipril) To treat congestive heart failure (varies) For kidney problems in diabetic patients (captopril)

What Are Other Off-Label Uses?

y y

ACE inhibitors may help prevent the onset of type 2 diabetes. In addition, ACE inhibitors may help control abnormal heart rhythms, particularly when used after a heart attack. ACE inhibitors are used off label in the treatment of such diseases as rheumatoid arthritis, migraines, Raynauds phenomenon and Bartter syndrome.

5. What are the common side effects?

y y y y y

Dry, persistent cough* Headache Fever and Chills Trouble Swallowing Upset Stomach

*Cough is a relatively common side effect from ACE Inhibitors. While this side effect is usually not a sign of a serious medical problem, you should report it to your doctor.

6. What type of adverse reactions should the nurse be aware of? Dry cough. 7. Are there any drug or food interactions the nurse should be aware of?

DRUG INTERACTIONS: The use of ACE inhibitors with potassium supplements, salt substitutes or diuretics , for example, spironolactone (Aldactone), that increase potassium in the blood may lead to excessive potassium levels (hyperkalemia). Potassium levels should be monitored whenever ACE inhibitors are used in combination with these drugs. There have been reports of increased lithium (Eskalith, Lithobid) levels when lithium is used in combination with ACE inhibitors. The reason for this interaction is not known, but the increased levels may lead to toxicity from lithium. There have been reports that aspirin and other nonsteroidal antiinflammatory drugs (NSAIDs) such as ibuprofen (Advil, Children's Advil/Motrin, Medipren, Motrin, Nuprin, PediaCare Fever, etc.), indomethacin (Indocin, Indocin-SR), and naproxen (Anaprox, Naprelan, Naprosyn, Aleve) may reduce the effects of ACE inhibitors. INTERACTIONS - Potassium-sparing diuretics may lead to hyperkalaemia. - Other diuretics may lead to hypotension. - Alcohol. - Alpha-blockers. - Beta-blockers. - Calcium-channel blockers. - Corticosteroids. - NSAIDs. - Potassium-containing drug
8. Should the patient take the medication with or without food? Is there a certain time of day the patient should take the medication?

ACE inhibitors are usually taken on an empty stomach one hour before meals. Follow the label directions on how often to take it. The number of doses you take each day, the time allowed between doses, and how long you need to take the medication will depend on the type of ACE inhibitor prescribed, as well as your condition.

9. What are the nursing implications for this drug class?

Hypertension should be managed according to appropriate guidelines. - Treatment with an ACE inhibitor can be started in the community in the majority of people with heart failure. - In patients taking diuretics, close supervision is needed when commencing treatment. - The initial dose of ACE has a risk of first-dose hypotension, therefore patients should be advised to sit or lie down for 2-4 hours after this. - Evaluate therapeutic response.

10. List at least the top three things you would teach the patient about these medications.

Never stop taking an ACE inhibitor, even if you feel that it is not working. If you are taking ACE inhibitors for heart failure, your heart failure symptoms may not improve right away. However, longterm use of ACE inhibitors helps manage chronic heart failure and reduces the risk that your condition will become worse. While taking this drug, have your blood pressure and kidney function checked regularly, as advised by your doctor. Advise patients to avoid driving and other hazardous work until they are confident that they have no dizziness or fainting from possible hypotensive side-effects. - Avoid excess intake of alcohol since this can enhance hypotensive effect. - This medication should not be stopped without medical consultation. - Advise patients to rise slowly in order to avoid postural hypotension.